I subscribe not because I'm a doctor, I'm an RN, but because I have the utmost respect and awe for doctors. I hear what you've been through. I don't know how any of you have learned the amount of information you have. I watch and twitch when I see you making extreme life and death decisions on the spot and then moving on. But, to the point, it isn't just MDs. I look at some nurses today and wonder why and how they got through nursing school. They do a job. They go home. Shift over. Tantrums if asked to perform a task not already written on what they perceive their agenda should be for the day. I don't hear in their voices or see in their facial expressions any sense of compassion, an urgency to do that little extra thing that would put that patient in pure contentment. I come from the generation where we stood up at the nurse's station so the doctor coming in could have a chair. Evening shift nurses gave every patient on their floor a backrub before the pt went to sleep. My friends and I were called into nursing. Doing the extra, staying a little later after you've clocked out, etc was the norm for us. It never occured not to do those things. I look around and I can see it and feel it - this virtuous profession is their 'job' not who they are. Thank you for sharing.
I've appreciated reading all the first-hand accounts of medical training and residency. I wonder if anyone would like to comment on the increasing role robotics play in the OR and the effects it's having on the skills of trainees. Is it worthy of its own Sensible Medicine post?
IEEE Spectrum, August 2022, pp. 32-37: "Today's Robotic Surgery Turns Surgical Trainees Into Spectators: Medical training in the the robotics age leaves tomorrow's surgeons short on skills."
Pre-med student here who just applied to medical school this cycle. I always enjoy reading your articles on here. This was a really nice read, and greatly appreciate every time you share your past experiences on here.
1975-76, first year resident in Internal Medicine at the University of Cincinnati General Hospital, short call, long call, no call, repeat, never leave an unstable patient regardless of call, no patient transport or phlebotomist at night, third year admitting resident either a rock or sieve, you hoped for a rock, walk through the tunnel to ED, transfer your sick as hell admission to wooden gurney yourself, transport patient to hospital bed, H&P, orders, draw all labs, start IV, before universal precautions blood not uncommonly on hands, do the ECG, LP, thoracentesis, paracentesis at bedside, transport lab specimens to central lab, gram stain fluids in resident lab, perform the cell count on CSF, carry the Lee and White clotting tubes around with you timing as you went, share a call room with everyone else, bunk beds, someone's pager always sounding, responding to every CODE, cool second or third year resident, you doing your part, watching, learning, glad someone else is in charge, one night decked by a round house thrown by a confused elderly man, stay beside your DKA, acute MI, septic patient, no sleep, present at morning report, speak with patient families, obtain autopsy permission for those you've lost, attend their autopsy, find out what you missed, pass out at home, repeat tomorrow.
My recollection hasn't become rosier with time, it was brutal, exhausting, sometimes demoralizing, but also thrilling with found knowledge, skills, critical thinking, the beginnings of self confidence, the love of this profession. We were not giants though we've all stood on their shoulders.
In the Netherlands, graduate medical education is competency based (you progress based on mastery) and
45 hours a week for 4-6 years. By and large the Dutch are extremely satisfied with their health care system. Makes one wonder whether our American arrogance has clouded our judgment about how things must be done. As the humanity in this post highlights, time for reflection would not be wasted on an intern
Thanks for the memories. Residency’s a bitch. Working secretly nights & weekends plus the GI bill to support a wife & 2 kids. Every week one or two disasters for the M&M monthly meeting. Finally survived and took a rural solo position. After 3 months of serene, no problem cases usually done by noon and very little call back or emergencies, I realized training wasn’t reality. This practice was!
I'm glad I read this write-up. Helped me to remember my residency days, some bad, some not so bad. I did my residency before the new rules went up, but I don't think I would change a thing. I was sleepless and tired most of the time, but I honestly think I learned a hell of a lot more than today's residents!
I have posted my comment as a reply to Dr. K. Medical training should be hard & should push trainees close to their limit, because the excellent practice of medicine demands it. Secondly, trauma for the physician is inherent in the practice of medicine. I fear that “the days of the giants” have largely come & gone.
I truly hope for a day when becoming an expert in human health is an embodied experience. Traumatizing our doctors in training is entirely wrong. Thanks for enduring it though. A voice of reason like yours is invaluable, especially now.
Lovely description of that transformational internship year. True then and even now, despite added safeguards and more humane schedules. That marrow deep sense of personal ownership of the death and disease swirling around you forever marks physicians and soldiers, especially the good ones. But we learn SO MUCH that year, relatively little in the formal curriculum. Recalls one of my favorite clinical aphorisms -- "Good clinical judgment comes from experience...and experience comes from bad clinical judgment!"
"The best treatment, then and now, was an oral antibiotic – trimethoprim-sulfamethoxazole."
Is trimethoprim available by itself?
"As Jim and I left the room I turned to him and asked, “what are we going to do?” Without missing a beat his response, “I don’t know Adam, it’s kind of the blind leading the blind today, huh?”"
You'd never hear that from a surgeon. "A surgeon may be wrong, but he's never in doubt." haha
"Our ever-present goal should be to assure that medical training is as difficult as it should be, maximally effective, and atraumatic."
You can get that at the same place where you buy fried ice.
Thanks Adam. I always wonder if the dehumanisation is a way of breaking down our pre-professional self, shattering it, in the hopes (sometimes realised) that we will rebuild a new identity . By this view, burnout is an essential part of the process. There need to be monitors and rescuers. Sounds like u had some. In most traditions, the process of becoming a healer requires sweat, suffering, and self-transformation. Robertson Davies meditates on this in his novel about a doctor, The Cunning Man.
I did a residency which, for years had 24 on/12 off/12 on/12 off. We got an extra day off every other week. We had a week's vacation but never got it. And we got paid $6000/year which was way ahead of the group before us who got paid nothing and who, as you noted, just lived/ate at the hospital.
It was exhausting as you describe but the learning was impossibly good. I am sure you are familiar with the studies that show that performance of residents who are now part of the clearly "kinder/gentler" residencies imposed a decade and a half ago is less-good (or at least no better depending on your study) than those of the more rigorous times.
But I look at my residents now and they are generally far less interested in being the best doctors they can be than my cohort was. Many of them have walked out in the middle of a DKA crisis because their shift was over -- if you do not work some of those kinds of events from start to finish (which takes more than a shift) there are important things you will just never internalize. And they will make a difference in someone's living or dying.
And I am not sure this can ever be made atraumatic nor am I sure it should be. Being a physician is one's life -- at least for my cohort it has been. The "work/life balance" so sought today makes one more a shift worker (e.g., hospitalists) who, while often smart and who try to absorb an impossible-to-absorb chart at the start of each shift often do so poorly (it is hard) and not only miss important items, but vary on their approach to the patient from shift to shift depending on whatever suits each of them individually. But they do go home on time when the shift is over. Their training/lives are more atraumatic but something is lost and it is not (in my opinion) unimportant or inessential.
I, too, have endless memories from my training years. But in hindsight I cherish every one from which I learned something that has helped me in the decades that have followed. Not all of it was good (some was bad...lol...and I was young and exhausted most of the time) but all of it was important. I despair that those we are turning out now will ever have the patient-centric wholistic view that we developed because we spent so much time and grief helping people live and, sometimes, die.
I think what you are seeing is a cultural problem that exists beyond medicine. There is a subtle nihilism that has insinuated itself into our culture. Something has superseded the more delicate desires to deeply know, care for, and understand humanity and the nature of our world.
Dr. K: As a retired physician, I agree with ALL that you have said here. I actually fear for the direction that medical care is headed. I’m compelled to share the following story. Recently my 92 year old father, who still lives independently, was hospitalized for a serious adverse reaction to newly prescribed Tamsulosin (Flomax) for BPH. He has a history of exquisite sensitivity to usual medication doses. After 10 days on Flomax, Dad became severely hypotensive & presyncopal. There was also a question of a new onset arrhythmia. Dad had a pacemaker/ defibrillator placed after a massive MI nearly 9 years ago, however he has been in normal sinus rhythm (NSR) for years. During my discussion with the young attending physician (hospitalist), who had tats & a notable Twitter presence, about whether or not an arrhythmia had been found, she insisted that he was being paced so that couldn’t be determined. Knowing his history, I was astounded. I continued to question this woman & it eventually became apparent that she had negligently read & accepted the printed interpretation on the ECG instead of interpreting it for herself. I was taught NEVER to depend on the print out. The hospitalist hadn’t bothered to read the ECG for herself or to look at his old tracings. During Dad’s post hospital follow-up visit with his cardiologist I recounted this story. The cardiologist assured me that although somewhat of a challenge to interpret, the ECG revealed a normal sinus rhythm.
There is no question that the quality of medicine has declined. Physicians are becoming more like 9 to 5 technicians as they become more & more dependent on clinical protocols established in an attempt to standardize care. The fact that most physicians are now employees is another problematic aspect. The covid-19 pandemic has shown a bright light on these problems & more. The decline in quality medical care is disturbing & needs to be addressed.
"most physicians are now employees" - quite a worry. While they may be spared a certain amount of drudgery they are subject to unreasonable time constraints as if there were a clock to life. My doctor remains in private practice but can't find a partner so relies on a solid CNP. We are at the same age of 83 and I dread his retirement. He like most professionals adores the work but IMHO is poorly compensated.
I subscribe not because I'm a doctor, I'm an RN, but because I have the utmost respect and awe for doctors. I hear what you've been through. I don't know how any of you have learned the amount of information you have. I watch and twitch when I see you making extreme life and death decisions on the spot and then moving on. But, to the point, it isn't just MDs. I look at some nurses today and wonder why and how they got through nursing school. They do a job. They go home. Shift over. Tantrums if asked to perform a task not already written on what they perceive their agenda should be for the day. I don't hear in their voices or see in their facial expressions any sense of compassion, an urgency to do that little extra thing that would put that patient in pure contentment. I come from the generation where we stood up at the nurse's station so the doctor coming in could have a chair. Evening shift nurses gave every patient on their floor a backrub before the pt went to sleep. My friends and I were called into nursing. Doing the extra, staying a little later after you've clocked out, etc was the norm for us. It never occured not to do those things. I look around and I can see it and feel it - this virtuous profession is their 'job' not who they are. Thank you for sharing.
Enjoying this substack and these reflections. Thank you Dr. Cifu
I've appreciated reading all the first-hand accounts of medical training and residency. I wonder if anyone would like to comment on the increasing role robotics play in the OR and the effects it's having on the skills of trainees. Is it worthy of its own Sensible Medicine post?
IEEE Spectrum, August 2022, pp. 32-37: "Today's Robotic Surgery Turns Surgical Trainees Into Spectators: Medical training in the the robotics age leaves tomorrow's surgeons short on skills."
https://spectrum.ieee.org/robotic-surgery
Pre-med student here who just applied to medical school this cycle. I always enjoy reading your articles on here. This was a really nice read, and greatly appreciate every time you share your past experiences on here.
Thanks so much.
1975-76, first year resident in Internal Medicine at the University of Cincinnati General Hospital, short call, long call, no call, repeat, never leave an unstable patient regardless of call, no patient transport or phlebotomist at night, third year admitting resident either a rock or sieve, you hoped for a rock, walk through the tunnel to ED, transfer your sick as hell admission to wooden gurney yourself, transport patient to hospital bed, H&P, orders, draw all labs, start IV, before universal precautions blood not uncommonly on hands, do the ECG, LP, thoracentesis, paracentesis at bedside, transport lab specimens to central lab, gram stain fluids in resident lab, perform the cell count on CSF, carry the Lee and White clotting tubes around with you timing as you went, share a call room with everyone else, bunk beds, someone's pager always sounding, responding to every CODE, cool second or third year resident, you doing your part, watching, learning, glad someone else is in charge, one night decked by a round house thrown by a confused elderly man, stay beside your DKA, acute MI, septic patient, no sleep, present at morning report, speak with patient families, obtain autopsy permission for those you've lost, attend their autopsy, find out what you missed, pass out at home, repeat tomorrow.
My recollection hasn't become rosier with time, it was brutal, exhausting, sometimes demoralizing, but also thrilling with found knowledge, skills, critical thinking, the beginnings of self confidence, the love of this profession. We were not giants though we've all stood on their shoulders.
In the Netherlands, graduate medical education is competency based (you progress based on mastery) and
45 hours a week for 4-6 years. By and large the Dutch are extremely satisfied with their health care system. Makes one wonder whether our American arrogance has clouded our judgment about how things must be done. As the humanity in this post highlights, time for reflection would not be wasted on an intern
Well written! I felt like I was there. Thank you for sharing your stories. God bless all the good doctors like you
Thanks so much.
Thanks for the memories. Residency’s a bitch. Working secretly nights & weekends plus the GI bill to support a wife & 2 kids. Every week one or two disasters for the M&M monthly meeting. Finally survived and took a rural solo position. After 3 months of serene, no problem cases usually done by noon and very little call back or emergencies, I realized training wasn’t reality. This practice was!
I'm glad I read this write-up. Helped me to remember my residency days, some bad, some not so bad. I did my residency before the new rules went up, but I don't think I would change a thing. I was sleepless and tired most of the time, but I honestly think I learned a hell of a lot more than today's residents!
I have posted my comment as a reply to Dr. K. Medical training should be hard & should push trainees close to their limit, because the excellent practice of medicine demands it. Secondly, trauma for the physician is inherent in the practice of medicine. I fear that “the days of the giants” have largely come & gone.
I truly hope for a day when becoming an expert in human health is an embodied experience. Traumatizing our doctors in training is entirely wrong. Thanks for enduring it though. A voice of reason like yours is invaluable, especially now.
Yeah, I'm distressed to read all the comments about "traumatizing residents is GOOD." No, it's not.
Graduated rutgers med 95 and did sinai NYC internship and residency til 99. Sinai training was a bear!
Lovely description of that transformational internship year. True then and even now, despite added safeguards and more humane schedules. That marrow deep sense of personal ownership of the death and disease swirling around you forever marks physicians and soldiers, especially the good ones. But we learn SO MUCH that year, relatively little in the formal curriculum. Recalls one of my favorite clinical aphorisms -- "Good clinical judgment comes from experience...and experience comes from bad clinical judgment!"
Thanks Andy
"The best treatment, then and now, was an oral antibiotic – trimethoprim-sulfamethoxazole."
Is trimethoprim available by itself?
"As Jim and I left the room I turned to him and asked, “what are we going to do?” Without missing a beat his response, “I don’t know Adam, it’s kind of the blind leading the blind today, huh?”"
You'd never hear that from a surgeon. "A surgeon may be wrong, but he's never in doubt." haha
"Our ever-present goal should be to assure that medical training is as difficult as it should be, maximally effective, and atraumatic."
You can get that at the same place where you buy fried ice.
Thanks Adam. I always wonder if the dehumanisation is a way of breaking down our pre-professional self, shattering it, in the hopes (sometimes realised) that we will rebuild a new identity . By this view, burnout is an essential part of the process. There need to be monitors and rescuers. Sounds like u had some. In most traditions, the process of becoming a healer requires sweat, suffering, and self-transformation. Robertson Davies meditates on this in his novel about a doctor, The Cunning Man.
Thanks John. Such a true observations. (And thanks for the tip off that you're a Robertson Davies fan!)
I did a residency which, for years had 24 on/12 off/12 on/12 off. We got an extra day off every other week. We had a week's vacation but never got it. And we got paid $6000/year which was way ahead of the group before us who got paid nothing and who, as you noted, just lived/ate at the hospital.
It was exhausting as you describe but the learning was impossibly good. I am sure you are familiar with the studies that show that performance of residents who are now part of the clearly "kinder/gentler" residencies imposed a decade and a half ago is less-good (or at least no better depending on your study) than those of the more rigorous times.
But I look at my residents now and they are generally far less interested in being the best doctors they can be than my cohort was. Many of them have walked out in the middle of a DKA crisis because their shift was over -- if you do not work some of those kinds of events from start to finish (which takes more than a shift) there are important things you will just never internalize. And they will make a difference in someone's living or dying.
And I am not sure this can ever be made atraumatic nor am I sure it should be. Being a physician is one's life -- at least for my cohort it has been. The "work/life balance" so sought today makes one more a shift worker (e.g., hospitalists) who, while often smart and who try to absorb an impossible-to-absorb chart at the start of each shift often do so poorly (it is hard) and not only miss important items, but vary on their approach to the patient from shift to shift depending on whatever suits each of them individually. But they do go home on time when the shift is over. Their training/lives are more atraumatic but something is lost and it is not (in my opinion) unimportant or inessential.
I, too, have endless memories from my training years. But in hindsight I cherish every one from which I learned something that has helped me in the decades that have followed. Not all of it was good (some was bad...lol...and I was young and exhausted most of the time) but all of it was important. I despair that those we are turning out now will ever have the patient-centric wholistic view that we developed because we spent so much time and grief helping people live and, sometimes, die.
I think what you are seeing is a cultural problem that exists beyond medicine. There is a subtle nihilism that has insinuated itself into our culture. Something has superseded the more delicate desires to deeply know, care for, and understand humanity and the nature of our world.
Dr. K: As a retired physician, I agree with ALL that you have said here. I actually fear for the direction that medical care is headed. I’m compelled to share the following story. Recently my 92 year old father, who still lives independently, was hospitalized for a serious adverse reaction to newly prescribed Tamsulosin (Flomax) for BPH. He has a history of exquisite sensitivity to usual medication doses. After 10 days on Flomax, Dad became severely hypotensive & presyncopal. There was also a question of a new onset arrhythmia. Dad had a pacemaker/ defibrillator placed after a massive MI nearly 9 years ago, however he has been in normal sinus rhythm (NSR) for years. During my discussion with the young attending physician (hospitalist), who had tats & a notable Twitter presence, about whether or not an arrhythmia had been found, she insisted that he was being paced so that couldn’t be determined. Knowing his history, I was astounded. I continued to question this woman & it eventually became apparent that she had negligently read & accepted the printed interpretation on the ECG instead of interpreting it for herself. I was taught NEVER to depend on the print out. The hospitalist hadn’t bothered to read the ECG for herself or to look at his old tracings. During Dad’s post hospital follow-up visit with his cardiologist I recounted this story. The cardiologist assured me that although somewhat of a challenge to interpret, the ECG revealed a normal sinus rhythm.
There is no question that the quality of medicine has declined. Physicians are becoming more like 9 to 5 technicians as they become more & more dependent on clinical protocols established in an attempt to standardize care. The fact that most physicians are now employees is another problematic aspect. The covid-19 pandemic has shown a bright light on these problems & more. The decline in quality medical care is disturbing & needs to be addressed.
"most physicians are now employees" - quite a worry. While they may be spared a certain amount of drudgery they are subject to unreasonable time constraints as if there were a clock to life. My doctor remains in private practice but can't find a partner so relies on a solid CNP. We are at the same age of 83 and I dread his retirement. He like most professionals adores the work but IMHO is poorly compensated.