In Which Your Uncle Panda Rips Off the Lid, Rolls it in a Tube, and Places it (Politely) Where the Sun Doesn’t Shine

Why Don’t We Starve Them Too?

As my regular readers know, I am opposed to the use of sleep deprivation as an educational tool during residency training. The fact that residents are deprived of sleep as a requirement of their job is undeniable especially given the typical call schedules and the obvious fact that work never stops in the 24-hour-per-day patient processing facilities that most teaching hospitals have become. And yet despite my objections I have never made much of an argument against this practice, at least in terms to which the usual advocates of resident abuse will pay attention, because my distaste is more visceral than intellectual. People do need sleep after all. It’s a biological requirement and I have never felt it necessary to explicitely justify why we need sleep any more than I feel it necessary to explain why we need food and water. We just do.

Imagine if it was a regular practice to deprive residents of food. I have no doubt that there are some with a great deal invested in mistreating residents who would indeed deprive of us food if they could make a case that eating interfered with Patient Care. I also have no doubt that many residents, in full Patty Hearst mode, would come out in favor of the practice. It’s just the nature of the profession, to gain admission to which many would sell their grandmothers to white slavers.
Fortunately, as residents can always cram a microwaved burrito into their mouths and suck down a luke-warm Dr. Pepper, the threat to patient safety is small and it hasn’t come to it yet. But imagine the outcry if it did…or perhaps the lack of outcry as the usual suspects opined that, back in the Good Old Days, they regularly went for weeks without food and the desire of the current generation of residents to eat is a sign of the impending medical apocalypse.

So why not starve residents? We deprive them of sleep every third or fourth day, why not make it a clean sweep and withold food and water as an additional character-building exercise, especially if we’re to operate under the theory that tired residents are as effective as well-rested ones?

Too Much Sun

The principle objection to allowing residents time to sleep is that limiting their hours interferes with continuity of care. It is correctly pointed out that the handoff, or the transfer of care of a patient from one resident to another, is a dangerous time from which all sorts of lethal misadventures can ensue. The new resident, after all, has not been following the patient and may not know the nuances of his condition or his plan. With this in mind, the theory is that by limiting the number of handoffs, the number of potential mistakes can be minimized. Limiting the number of handoffs means keeping the residents at the hospital longer.

Now, I am sure that there is a growing body of competing and contradictory studies comparing the risk to patient safety of the handoff versus sleep deprivation. Both probably result in mistakes but as to which is the worst I can only confess a profound indifference. I don’t care because the premise of the studies, that patients in teaching hospitals are at a significant risk, is so deeply flawed as to make the studies meaningless. This is not to say that there is no risk of mistakes but only that by the very nature of academic hospitals, the risk of mistakes is considerably less than it would be at a hospital without residents. This is obvious to anyone who has ever been in a non-academic hospital but maybe not so obvious to those who, like heat-stunned lizards laying on sunbaked rocks, may have been staring into the dazzling fire of academic medicine for just a little too long.

Consider the typical patient at a hospital which does not have residents. The patient is admitted either through the emergency room or directly from his own physician who most likely will not actually see the patient at the time of admission but only relay a few phone orders to the nurse. (This is especially true of a patient who comes through the Emergency Department.) The patient then languishes until the next morning, at which time his doctor will quickly rounds on his census of admitted patient, writing more orders as needed to solidfy the plan, before heading to an extremely busy day in his clinic. Once he leaves, barring a catastrophe, the patient is on autopilot until his doctor checks on him at the end of the day to write new orders or call for any consults which he has not previously anticipated. Many patients only see their doctor, if at all, for a few minutes during their stay while many others are fobbed off to hospitalists, the hired guns of primary care.
Patients in teaching hospitals, by comparison, are positively coddled. Consider the typical service with its census of fifteen to twenty patients riding herd over which is a senior resident, a couple of junior residents, an intern or two, and often a gaggle of eager medical students. Not to mention an attending physician who, liberated from the exigencies of mundane bureaucratic tasks, is free to concentrate his entire intellect on diagnosis and treatment. Comes the night, the prelude to all manners of medical horrors, and there are several residents from the service actually living at the hospital ready to address any problems, from a request for a sleeping pill to cardiac arrest. Not the full complement of physicians to be sure but as doctors in private practice do not spend the night in the hospital, I fail to see how patients in a teaching hospital are worse off than those poor bastards starving for attention in private hospitals. As to the dangers of handoffs, I’m reasonably sure that I do a better job of signing out my patients to my fellow resident than the private practice physician does to his colleague who will be taking over his call duties, duties that they both can generally perform from home, especially as the standard advice to any patient inquiry, no matter how non-threatening, seems to be, “Go to the emergency room.”

So you see, “Medical Errors,” like “Patient Care,” is nothing more than another blunt weapon with which to bludgeon rebelious residents into submission. It is another despicable appeal to shame and an abuse of the resident’s sense of duty. The fact that most residents buy this argument is because they lack the conceptual tools to refute it. But if you think about it, if handoffs are so dangerous, we may as well never leave the hospital but instead live there, perpetually on tenterhooks, agonizing over every detail and jealously guarding our patients from interlopers like feral dogs over scraps of meat.

38 thoughts on “In Which Your Uncle Panda Rips Off the Lid, Rolls it in a Tube, and Places it (Politely) Where the Sun Doesn’t Shine

  1. The reality of medical practice after training is that long hours will be commonplace. The public has the expectation that their doctors will be available on demand at any hour, especially in my specialty of intensive care. We continue to do our residents a dis-service by not expecting them to be able to perform under stressful/fatigued conditions. Generally those who write these rules (80 hr work week) have good intentions, but likely have forgotten or have never had to perform under conditions less than optimal. Ask any of the returning physicians from the Iraq war if they are not grateful for the stress they underwent in training. I suspect I know their answer. Practicing medicine is not easy and not for everyone who graduates from medical school. As someone wiser than me said, “If you can’t stand the heat…”

    (Whoa. As I may have mentioned a time or two, I was a Marine for almost eight years and not just any old Marine but a Marine Infantryman who was doing the military equivalent of hard time. I mention this because the heat of being an infantryman is an order of magnitude hotter than the heat of being a resident and our kitchen makes your kitchen look like a butler’s pantry. In other words, not only do I have a basis for comparison of the level of difficulty of many other activities but I also am somewhat immune to appeals to manhood or that I should just “suck it up.”

    The point is that sleep deprivation in residency training is pointless and mostly a function of the inefficiencies of a system that can only exist because it is fueled with incredibly cheap, powerless labor…what the AMA once called the last legal sweatshop in America. If the system wasn’t so inefficient, there would be no need to work residents even sixty hours a week, let alone eighty. I am reasonably sure that great swaths of my time have been wasted on useless bureaucratic activities of a type that is unheard of in private practice.

    On your other point, as I don’t plan to seek a commission in the military as medical officer and am now too old to even be considered for the draft or reenlistment, the odds of me ever again serving in the military are zero. So, assuming that being sleep deprived builds up your tolerance for sleep deprivation (but it doesn’t you understand) of the kind that I would encounter in a field hospital in Iraq, my question is, “So what?”

    As to the expectations of patients, they will just have to eventually learn to live with their disappointment. There are plenty of old-school physicians, presumably inured to the hardships of medicine, who are punting their inpatient responsibilities to hospitalists, themselves working on shift systems without call, so obviously I am not the only slacker in the bunch. I would say that the physician who works eighty hour weeks and loses sleep one night out of four is the minor exception, not the rule, and is doing so from some inner drive, either to make more money or for professional satisfaction and not because he is forced to.-PB)

  2. I graduated medical school in 1987, several years just prior to the on going discussions of resident hours. I was first a medicine intern and then resident, and then (just for the punishment!) a psychiatry intern and resident. The hours were brutal. More so for medicine then psych, but still just gruelling. It was part of the culture, part of the way life was, you just did it, and learned to survive.
    There is a real benifit for this kind of education, however, that I rarely see refered to. When you are up in the middle of the night doing something, there is a real need to do it right, and do it right the first time, because then , maybe, you can go (back?) to bed! If you screw it up, the nurses etc are calling you, and wow! no sleep! In this kind of situation lessons are learnt fast, and very thouroughly! There’s no time for the miriad of daytime distractions like gossip and lunch and rounds and lectures and families etc etc. There is only the clinical situation and learning in its most sublime and efficient state!

  3. I graduated with an MD/PhD in neuroscience and I started my training in neurosurgery in Philadelphia in 1998 prior to the new policy limiting resident hours. At the time, I was 32yrs old with 2 young children (2yrs & 6mos old). I worked the 120hr weeks at a very active trauma center and spent all night up, every other night, caring for patients and often didn’t sign out post-call until 10p (still no sleep) having to then go to medical records to dictate charts for a couple of more hours just to get unsuspended for the next day. I’d get home by midnight and have to be up at 4am to return for the next day. After a couple of months of that physical and pyschological torture, I became more and more depressed, angry all the time from being yelled at by nurses and attendings and myself yelling at nurses, patients, and med students. I increasingly found myself crying in the call room alone and feeling helpless and hopeless. By 6 months into my internship, I had hardly ever seen my children awake and my wife felt I was becoming more and more distant. One night during a particularly brutal call, I found myself facing a list of ~65 patients for whom I only had a name, room number and diagnosis and a beeper that wouldn’t stop going off. That night I felt like there were 2 ways out — one was off the roof of the hospital and the other was out the front door. Thank God I had the strength to choose the front door. That day I quit and never returned and I have never regretted that decision which saved both my life and my family. I re-matched in Pediatrics and completed my medical training thankful for only having to work 80hr weeks (imagine that?!). I still get emotional recounting those difficult times. Was it necessary to make me work 80-120hrs in order for me to become a ‘good’ physician — absolutely NOT. It dehumanized me and I can assure you that patients don’t benefit from the care of dehumanized physicians. How can you care for someone else if you can’t even care for yourself? Forget 24hrs, NOBODY should be expected to work longer than 12 continuous hours with full days off during each 7 day period. Anything else is INHUMANE and unecessary and benefits nobody. As dramatic as my story may sound, it is hardly unique. I’m glad there has been some progress with this very important issue, but there is much, much more to accomplish and I salute those making a stand.

  4. Continuity of care must be preserved for the good of the patient! Nurses work 8-12 hours and then sign off their patients to the next shift. Where is the continuity of care! How can a new fresh nurse who doesn’t know the patient provide continuity of care. How do you think so many medical errors occur? It’s lack of this beautiful and wonderful thing called continuity of care. I propose that the Residents and nurses who admitted the patient stay in the hospital until that patient is discharged. If we adhere to this new rule the patient will have the continuity of care that is so vital to mimimize medical errors.

  5. i’m all for starving the residents – most are too fat and eat too unhealthy.

    however let them (us) sleep for god sakes, also i think we should let the patients sleep no more blood draws q2 hours between 10 pm and 6am

  6. Ah, but there was a time when the residents did live in the hospital in dormitories, weren’t paid, had no families, and were all white men. Why can’t we get back to the good ol’ days?

  7. All these studies looking to whether resident work hours harms patient care are missing the point. If patients are harmed, the public thinks that the status quo should change; if patients are not harmed, then the status quo should remain as such. Where are the studies that ask whether or not the current system harms the residents? I don’t really care if the studies say patients are or aren’t harmed. Either way, sleep is good and necessary and I agree with Panda that sleep deprivation during residency is unnecessary in a well-managed healthcare system.

    Of course, since we don’t have one of those, we should obviously focus on teaching residents how to survive it once they are doctors (by no sleeping) rather than doing spending our resources to fix the damn healthcare system in the first place.

    (Exactly.  And I reiterate my main point that I don’t actually care whether studies show that patients are or are not harmed by tired residents.  It should be irrelevant because the natural progression of showing that tired residents are safe is to make us work as many hours as we can possibly work before the psychosis of sleep deprivation sets in, in a sense using research to perpetuate something that, if it where done to our terrorist prisoners in Guantanamo Bay, would be considered a war crime.   Can my many critics see this obvious but important point?  Obviously not but I don’t know how much clearer I can possibly be on the subject. 

    The fact that many believe it takes more than eighty hours a week to train anybody in any profession, especially as they have from three to seven years to do it, is ludicrous.   Absolutely ridiculous.  the problem lies in the structure of residency training and the outright fraud of collecting money for resident education from the government and then also extracting money-making or money-saving (which is the same thing) work out of the residents. 

    Look at it like this.  Suppose that, instead of receiving a stipend from the hospital for our services the government gave us the entire $120,000 or so per year the hospital gets per resident and allowed us to pick which program we wanted to give it to.   How long do you think the system would continue as is?  About an hour.  It only creaks along because change comes slowly and there is still no incentive to tighten things up.  Even the vaunted “80-hour-rule” is a guideline and carries no legal weight in 49 states.-PB)

  8. QUOTE:

    “There is a real benifit for this kind of education, however, that I rarely see refered to. When you are up in the middle of the night doing something, there is a real need to do it right, and do it right the first time, because then , maybe, you can go (back?) to bed! If you screw it up, the nurses etc are calling you, and wow! no sleep! In this kind of situation lessons are learnt fast, and very thouroughly! There’s no time for the miriad of daytime distractions like gossip and lunch and rounds and lectures and families etc etc. There is only the clinical situation and learning in its most sublime and efficient state!”

    First of all, from what I hear, you won’t get to “go back to bed” even if you do it right – there’s too much other work to do.

    More importantly though, this same argument could be made for airline pilots. If they are flying at night after a day of flying, they will have to focus that much harder and they will realize how much more critical a single little mistake might become. Lessons will be learnt and learnt thoroughly!! There is a real need to do it right and do it right the first time! Therefore, I propose that the FAA change regulations in order to allow airline pilots to fly up to 36 hours straight with no sleep, and up to 100 hours per week.

    When you say you’ll be willing to get on a red-eye flight with a couple of these pilots who’ve already been up 30 hours, I’ll say I’m willing to a patient with a doctor who’s been up the same….

  9. I’m a tech at a large teaching hospital (I make a distinction between academic medical centers and “community hospital where residents get trained”). I work ungodly amounts of call (on for 48hrs straight every week). I can definitely agree that long hours create mistakes. My only diagnostic error I’ve ever made occured around 3am on a Sunday morning. I actually spotted a thrombus, and by the time I’d returned to the lab to write it up, I’d forgotten what I saw and marked it as “normal.” The interpretting physician, knowing that I am good at what I do, didn’t double check me and dictated it as normal (oops). Besides, the doc has probably been up for 20 hours too.

  10. You might be interested to know that a definitive RCT on the effects of sleep deprovation on medical errors and patient outcomes has never been performed. Why? Because it’s impossible to find a hospital who will agree to be the trial (i.e. sleep) arm of the study. Interestingly, they’ve thought of using European hospitals as a control — nobody works more than 50 hours a week over there, even during residency — but the health care systems are so different, it would be difficult to compare.

    I unfortunately don’t see this practice coming to an end any time soon. The stakeholders have way too much invested in squeezing every last drop of work out of the residents. It seems it’s one of the few ways hospitals think they can make $$.

  11. Some of my best learning nights were up all night in the ICU as a medical resident, typing in orders with one hand, and reading the WAshington Manual with the other. Or putting in lines unsupervised, not certified, and just holding my breath. Or staving off a code (I guess rapid response teams do that now).

    It sucked being up all night, but it made me a better doctor. There’s arguments on both sides.

  12. I wish I could remember the reference, but I recently spoke with Dr. Charles Czeisler, a sleep medicine physician, who has been publishing high-profile studies and has been pressing for lowering the shift hour limit even more than 80 hours per week. When I asked him about the question of handovers, he referred me to a study that focused on that process and tested some very simple changes involving electronic records: in the end, there were no additional errors or worse outcomes as a result of increased handovers (and shorter shifts for residents). That is to say, it isn’t difficult to improve handover procedures so that the incoming residents are up-to-date on the conditions of the patients. After all, you lose the ability to consolidate memories as you become more sleep-deprived, so how are you going to remember everything you need to tell the next resident when you’re running low on fuel?

  13. “Some of my best learning nights were up all night in the ICU as a medical resident, typing in orders with one hand, and reading the WAshington Manual with the other. Or putting in lines unsupervised, not certified, and just holding my breath”
    Some of my best learning nights were spent as a night float resident, putting in lines unsupervised, not certified, and just holding my breath. The learning came from being relatively unsupervised. That I could sleep during the day and was not sleep deprived made it easier to learn.

  14. Being up all night with no sleep does not make “best learning nights.” The best learning comes when YOU are given the responsiblity to care of your patients and the decisions are up to YOU. Depriving anyone of sleep is not a good idea. Doctors are not different in their physiological needs than other human beings. Anyone who thinks that depriving docs of sleep is a good idea, should be starved.

  15. panda,
    folks like you are either not in medicine in great numbers or are scared or are of the mind that “well i had to do it so you do too”.

    as you say in your post, critical thinking is a crucial part of medicine but for some reason doctors do not turn their critical thinking skills towards their own profession and how we train physicians.

    certainly there is an element of fear here that voicing these opinions, especially while a resident, will simply get you singled-out as a ‘trouble maker’ or someone with a ‘bad attitude’, but if docs would simply think like attorneys think then the questions you ask would come fast and furious and there really is no logical refuatation to them.

    we are, in a very real sense, like the mafia. you cut your teeth for the profession by single-minded dedication and you break in. you sacrifice for the profession and move up. meanwhile, your time invested skyrockets, your debt does as well, and gradually you become part of the mob. there’s no getting out, as they say, and eventually you want to silence those who would criticize or harm your ‘family’. the alternative, for many, is unthinkable.

  16. Interesting posts and comments. I was supposed to have surgery this past winter in a teaching hospital because I was considered high risk.

    I would have preferred staying in my community hospital but my urologist wanted me where there was a urology wing ,where they would be more experienced at caring for me during the critical post op time and also where there were docs 24/7.

    I trust him implicitly but was sometimes unnerved by things I had read in the blogosphere regarding teaching hospitals. Like the monkeys run the asylum between May and July and so don’t ever be a patient in a teaching hospital at that time of year. Or the sleep deprivation issue, etc.

    Fortunately for me it appears to be a moot point as I am healing. But if for any reason I do have to go into such a facility I will feel a bit more at ease because of this post. Dr. Schwab helped me at the time too.

    Overall,the collective knowledge shared on the blogosphere is greatly appreciated by this girl! 🙂

  17. “Some of my best learning nights were up all night in the ICU as a medical resident…it made me a better doctor.”

    I agree with the poster who said that the learning part came from being unsupervised, not from being up all night.

    Beyond that, my comment here is that the question is not whether being a resident in the current system of sleep deprivation makes you a good doctor, but whether it makes you a better doctor than you could be under any other circumstance (ie. not sleep-deprived). There are VERY few things in this world that you learn better while sleep-deprived. The biology just doesn’t work that way.

    As I stated previously, my contention being sleep-deprived only teaches residents to cope better with being sleep-deprived and thus how to cope in a system that requires it, not because that is the only system available, but because too many people think the system is a good idea or that it is too hard to change the status quo. Sleep-deprivation does not equal “best way to make a good doctor.”

  18. Actually my friend and I were talking the other day about how useful it’d be if we didn’t have to eat… mostly so that this way, we wouldn’t have to sneak time to, uh, poo while on service. Where can we hide? When? IT IS ALL MUCH TOO COMPLICATED.

  19. We could also pump oxygen into the hospital air just like they do at casinos to keep the residents working on that little bit of euphoria that a higher pO2 brings. But wait, then the oxygen for the patients would be used up faster getting in the way of patient care and driving up the overhead…couldn’t do that.

  20. So are you willing to do an extra year of residency in order to work more reasonable (less)hours? Or do you want to have your cake and eat it too?

    Going from 80 hours per week to 60 would require another year to make up the hours.

    (Residency training is needlessly inefficient and residents have their time wasted wholesale. It is not a “eat cake and have it too” kind of thing.  Cut the hours and there will be an incentive for the hospital to not waste our time.  The idea that we can’t train anybody for any job given five years (for surgery as an example) of 60 or 70 hour weeks is ludicrous.-PB)

  21. I believe it is a false premise that cutting residency hours (to 60, using your example) would require an additional year of training.

    Even so, my answer is actually YES. I would trade another year in residency for those 20 hours a week. For the most part (ignoring certain malignant specialties and programs) what makes residency so miserable is the long/inhumane hours. To have a job (like I had before medical school) where I work 50-60 hours a week means I get to have a personal life too; I get to be well rested, I get to see my husband, my family remembers I am related to them. So, even though it is unnecessary, I would certainly trade off being a resident for an additional year if it were not designed specifically to run me into the ground.

    (Exactly.  I am on the “four year plan” for what’s supposed to be a three-year residency so I have a little experience in extended training.  Unfortunately I did two standard intern years so I reaped no benefit.  Assuming I buy into Scalpel’s premise, I bet most people would rather do an extra year of training in exchange for being well-rested and having time for a personal life.  I just don’t buy the premise that sleep deprivation serves any other purpose but making money for the hospital by having minimum wage captive labor working at jobs which in the real world are filled by people making six times as much.

    I also fully agree that the best training occurs at night when residents have minimal supervision.  But that only means that residency training for the 24-hour-per day specialties should be on a shift system like we do in Emergency Medicine.-PB)

  22. There is experience benefit to be gained from the daytime work too, which the hypothetical night-shifters would miss (as well as the lectures and conferences and such). It seems like quite a stretch to suggest that the same quality of training could be obtained in 3 years of 60 hours per week as three years at 80 hours per week.

    But moving from a 3 to a 4 year program would give the older residents more time to sleep and see their families, and it would give the younger residents more time to moonlight and earn extra cash, so both groups would benefit.

  23. Based on the arugment that much more can be learned in 80 hours years than in 60 hours, I propose that we go back to the good old 120hr weeks. Think of the benefits of an additional 40 hours of training!
    Residency training and medical school in general have so many hours of wasted time. I remember in my surgery rotation I showed up at 4:30 every morning to round on a few patients and hold the retractors like a mindless monkey. What a pathetic waste of time, I’m still bitter.

  24. Well we could cut it to 20 hours a week, mostly done in the comfort of your home on the computer if you like. I’m sure you would be trained just as well, and you could sleep all you wanted, eat as often as you like, and spend a lot more time with your family that way.

    All that unpleasant hospital work is probably superfluous for those of you who already know everything.


  25. Please scalpel, no one is saying here that residency is UNNECESSARY in terms of training.

    Concisely put, my (I would write “our” but I know better than to speak for others) points are a)80 hours a week would be unnecessary if the system were run more efficiently; b)the only benefit of the current system (to the resident) is that it teaches you how to survive in a broken system that ought to be reformed; c)hospitals benefits more from the current system than the resident and I wish they would just come out and say it instead of hiding behind the “it’s for your own good” line; and d)depriving people of sleep and their families is unhealthy (and I am not talking about the patients here but throw them into the argument too if it helps).

    I even went along with the “60-hour” example. I’m not saying I don’t want to work; I am saying that the current system only exists because it has not changed yet and it is illogical in my eyes to insist that it could not be done in a better way. You’re not talking with people who never held a really job here. I was on salary, not paid hourly, and I worked each week until the work was done. Some weeks that was 40 hours, some week it was 60 or even 70. I believe that I even worked 80 hours, when I had a deadline and a demanding client. The point is that you do what you need to do but to think it is NECESSARY to do that every week for 3-5 years (or longer) in order to be a good physician makes absolutely no sense to me. If my employer had told me I needed to work 80 hours EVERY week regardless of the level of work to be done OR because they couldn’t afford another person in my position to do the other 40 hours of work (fallacy anyway and not my problem), I would have told them to shove it and walked.

    And YES good learning happens at night. I am not adverse to working at night. Block scheduling of shifts over 3 years should give adequate time for instruction and learning. Despite apparent suggestions otherwise, residents are not, in general, idiots.

  26. You know I typed this big long comment last night and the internet decided to give me the finger and refuse to post it.

  27. “There is experience benefit to be gained from the daytime work too, which the hypothetical night-shifters would miss (as well as the lectures and conferences and such). It seems like quite a stretch to suggest that the same quality of training could be obtained in 3 years of 60 hours per week as three years at 80 hours per week.”

    Float the night shift. Problem solved.

    I disagree with the second statement made. Simply hark back to your pre-clinical years, when you would study two hours hard and get more work done than some who studied for six hours lazily (chatting, surfing, etc.).

    I’m reminded of Ralfie’s dad in A Christmas Story. “Work smarter, not harder!”

  28. You’re both assuming that you can increase the intensity and quality of training on your terms. I think that is laughable. I’ve gotten the feeling from various commenters that they think pre-rounding is BS, that rounds are BS, that assisting in surgery is BS. Just what part of medical residency do you think is important? Only the good cases? The unsupervised call shifts are great, but if you leave first thing in the morning you miss some feedback on your performance.

    Do you really think you can make all the good cases line up at your request each day so you can get home on time? Good luck with that,

  29. I thought I’d share my recollections of my internship at the Medical College of Pennsylvania (MCP) that I’d once posted on a Phila. newspaper discussion board after the AHERF bankruptcy.

    I wrote then:

    … I remember leaving MCP for the last time very well. I drove out, saw it in my car’s rear-view mirror, and said I’d never return.

    It was late June 1982. I had just completed my medical internship there under Donald Kaye, who was chair of Internal Medicine at the time, and later became AHERF Eastern Region CEO.

    The internship was brutish, with myself (valedictorian at Philly’s George Washington High School, 1974, and graduate of Boston University’s Six-year accelerated medical program) and my colleagues being treated like slaves, harassed, made to work long hours on-call (the 8 AM-to-6-PM-the-next-day-straight-through stuff) with little or no sleep and little or no ancillary support. For example, we were responsible for most IV placement, nighttime blood work, EKG’s, and other “scut”, in addition to handling admissions from the ER and floor emergencies, and treated rather contemptuously.

    I can remember many unpleasant events quite well. I will write of only a few.

    I was assigned a Resident when I first started who could only be described as a bully. He was mean-spirited, intimidating and unhelpful, and seemed to delight in his new interns’ difficulties. Team morale was nonexistent, and I nearly quit the internship after a month with this person.

    In addition, this Resident made me so nervous that I stuck my finger (July or early August 1981) with a needle drawing blood from a person who I later found out happened to represent one of the earliest cases of heterosexual AIDS transmission in Pennsylvania. Fortunately I remained negative, once testing became available for HIV, although at that time (before the disease was well-understood), one can only imagine the fear, uncertainty and doubt I went through for several years.

    I then had an attending physician (on 5 North) who believed in sadistic hazing. She had apparently been a Philadelphia school gym teacher prior to going into medicine and seemed to treat men differentially (and ina bad way) … She insisted that interns on call at night must repeat any tests done by the lab, such as CBC, gram stains, urinalysis, etc. MANUALLY for inspection the next morning.

    This was not easy to do considering we often had up to a half dozen new admissions at night, plus had to handle floor emergencies and IV/bloodwork…we were reprimanded if we failed to meet that goal (orally, and in writing on our evals). Another such rule was imposed on us: any woman admitted at night for ANY reason must have a pelvic exam and pap smear, if not done in the past year, BY MORNING, with slides available for inspection. NO EXCEPTIONS! Imagine doing a pelvic exam on patients such as an elderly woman with severe, widespread neurofibromatosis from Inglis House (a place for mentally normal but seriously physically impaired people), admitted for sepsis, late at night… Intimidation was a daily sport for this attending…She also did not trust nurse’s vital signs measurements and intimidated interns who quoted figures from the Vital Signs clipboard outside each room. She insisted interns take every one of their patient’s vital signs and ignore what the nurses had done, every morning. As if we really had time for that…There was no effective grievance process about this.

    Anyone who complained was labelled “immature” or defective in some way. Some of us were actually told after busy nights with no sleep, in front of the team, lines like “we were unfit to be physicians.” My resident had to restrain me from verbally abusing this attending, which I was assured would have likely ended my career.

    An intern who preceded me on that service confided he was severely depressed and nearly to the point of nervous breakdown and self-harm by the time the rotation was over. He said that if he’d stayed on her service for one more day he’d have jumped out the 5th floor window, House of God style. And I believe he was serious.

    Our paychecks were withheld if we did not complete our chart discharge dictations, an unpleasant process especially during an exhausting internship when there was little time for outside activity, so a number of us did not get paid for several months at a time. One dermatologist there actually harassed my parents on the telephone when his patient’s chart had not been promptly completed to his satisfaction. As it turned out, he had mistaken my father for another person of similar name who’d apparently not paid him for some service rendered! No apology was offered, and I had to avoid this cheerful fellow…

    Needless to say, interns do not provide the best of patient care under such circumstances.

    I left the institution and completed my residency at Temple Univ. and Abington Memorial Hospitals, which I found far more humanitarian.

    I went on to an NIH postdoc in medical informatics at Yale after a few years of practice.

    I can say with great assurance that this internship experience was destructive, wasteful, and nearly led me to quit medicine altogether. My leaving direct clinical care dates to the objectionable experiences I had as an intern at MCP.

  30. Random MSII on August 23, 2007 4:19 pm asks:

    “Where are the studies that ask whether or not the current system harms the residents?”

    Do a PubMed search on “residency sleep deprivation” or similar. Then use the “find related articles” option on relevant hits. There’s-a-plenty.

  31. I never said residency is BS. I only implied that in many rotations as a medical studeny you have to to do BS work and most of your time is so horribly wasted that it isn’t even funny. I mean we actually pay for this. My first rotation was surgery and my time was wasted to no end. I soon learned that most of the knowledge you gain is through self-study and hard work. You don’t magically become competent by following around those in longer coats. In reality all of medicine is a losing battle to which we will all lose to DEATH!

  32. Holy crap, Silverstein and MD/PhD.

    I mean, really. Holy crap.

    Why do people put up with this horrible abuse? Glad you both made it out alive.

  33. This discussion of residency programs at KU aired last week on NPR. I am always amazed at the seemingly rational people who will argue to no end that residency years must now be extended because 4-7 years is simply not enough time to train doctors under the restrictions of a 80 hour work week, let alone the possibility of further reform, because, “obviously” they will be seeing fewer cases. The dread of the reality you described above is what caused me to pursue other fields after college, but here I am again, applying to med-school for Fall ’08, older, but perhaps not wiser. I am glad I have found your site, btw. At the risk of sounding like a teenage girl boy-band groupie, reading it is like coming home after an extended sabbatical on a foreign planet.

  34. I’m sorry that you will be discontinuing this blog; I only discovered it recently, but your views on residency very much parallel my own. I did an internal medicine internship and residency at New York Hospital, and those were the three worst years of my life.

    I particularly agree with your Patty Hearst references. I’ve often compared residency training to a religious cult. (Sleep and food deprivation, physical rigors, and the constant brainwashing that your Chairman is God…)

    Good luck to you!

  35. It makes me nervous starting medical school next fall and reading my future as being “sleep-deprived” and “inhumane.”

    Don’t get me wrong, as sick as it sounds, I am sort of looking forward to getting my ass kicked during medical school and residency. Personally, it could be a good thing for me. I want to be forced to work very hard. But inhumane? That I don’t need. Is it possible to seek out a residency program that is not this way? Do they even exist?

    Especially for sleep, I don’t function well at all on no sleep.. I notice my normally happy outgoing disposition turns into “please don’t talk to me.”

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