I'm a medical resident at a prestigious teaching hospital. I hate to admit it, but I've lost my empathy already.
The experience most interns have on day 1 is a massive increase in responsibility and work load as compared to medical school. Whereas most medical students in their 4th year "manage" (under the very close supervision of residents) 2, 3, or maybe 4 patients, on day 1 of intern year they are suddenly expected to be responsible for upwards of 10-12 patients (under supervision, but considerably less supervision than med students). Interns go from spending most of their time studying and learning medicine, to being suddenly, constantly busy with often mind-numbing tasks. We interns joke that we are nothing more than secretaries, doing tasks for our boses all day without time to sit down and think for ourselves, despite the M.D. we just spent years earning. Eventually, we get better at prioritizing, we learn the system, and we learn by doing.
But, early in intern year, we can't prioritize, we don't know the system, frankly we can't even keep which patient is which straight in our heads. But, regardless, we still have n number of tasks to do by the end of the day.
Spending extra time talking to patients isn't part of n. Empathy isn't an item in n. Figuring out a patient's priorities for their health aren't an item. Those are extras.
And to get home on time, after my 12-14 hour shift, all I have to do is my list of n tasks, which is substantial. So, we quickly learned that long conversations with patients are the enemy of getting home on time. And pretty quickly, we start to eliminate those conversations. Then, we figure out that other things patients need, like empathy, a careful history taking and detailed physical exam, family discussions, etc also stand in our way of getting our work done on time.
Eventually, we learn the ability to keep our patient's complex medical problems straight and become much more efficient at getting our work done quickly. So, realizing we have more time, some of us go back and start to do the things that really matter to patients, like those things listed above and in the article. But, we've already learned, or forced by the system to learn, that we can get away with not doing those things, so as soon as we get a little extra busy or are a little extra tired, those are the first things we skip.
Then, suddenly, we start second year and can now be asked to work 24-28 hours straight, and now we have 18-24 patients instead of 10-12 that we are responsible for and the system again drains us of the very thing we enrolled in medical school to be.
And you're certainly not to blame for that. As an intern and second year, you're at the bottom of the food chain. You have to run this perverse gauntlet where you're burdened with most of the labor while attending physicians swoop in for a brief moment of lets-play-House, else you'll get on superiors' bad sides, you'll be seen as a weak link, co-interns will feel as if you're shoving your duties onto them, or at the very least, you'll be forced to sacrifice personal time for yourself and/or a partner. There's a ton of pressure, and the easiest fat to trim is time not spent getting a blood draw, calling the lab, or requesting a consult, even if chatting lightheartedly with a patient or taking the time to educate them on their condition could prove just as valuable a use of time.
To be frank, this is why I've decided to leave medicine proper altogether and to go down the startup route. Not only do I find startups more interesting, but I genuinely believe that a much bigger impact to patients' health could be achieved while maintaining my empathy, sanity, and life. I don't mean to denigrate you in anyway. If anything, you're far brave than I am.
24-28 hours straight? This shouldn't be legal if you ask me. Even truck drivers are way more limited to how long they can drive by the DOT. Sure, you are moving around which might keep you more alert than a truck driver but anything beyond about 16 hours max (depending on the person) really just seems like asking for trouble. (eg. mistakes) And when those mistakes could be someone's quality of healthcare, even their life, it should be deemed unacceptable.
As someone not in any way related to the medical industry, I want to ask what broke: if interns are overworked, and /or overqualified (I have a hard time seeing a justification for effectively secretaries having doctorates), then where is the pressure (more compensation, reduced barriers to entry, etc) for more of them if those already in the industry are incapable of being healthy with their workloads?
Is this just one of those cases where, if you made it through medical school for an obscene number of years, you "don't care about the money", and thus just take whatever you can get in industry?
From what I hear around here (again, not in the medical industry at all and never really interact with it besides as occasional chauffeur for relatives) it is just an over-regulated mess that makes market forces impossible to act on it. Is it any better in some of the single payer nations without as much bureaucracy? Or is there even more on that side of the circus?
> Is this just one of those cases where, if you made it through medical school for an obscene number of years, you "don't care about the money"
I think it's more like "holy shit I have $300k in medical school loans, I better put up with whatever I have to in order to become an attending."
> makes market forces impossible to act on it
I believe (though I could certainly be wrong) that market forces are actually mostly responsible. Because a medical intern's negotiating position is pretty weak (they're saddled with medical school debt, they still require a great deal of on-the-job training), hospitals are well aware that they can torture interns because the alternative is pretty grim - even if you went off and became a software developer at Google, $300K in student loan debts will eat up pretty much all of your salary.
But logically if interns were being exploited by hospitals and burdened with tremendous debt then potential MDs would stop going through the program seeing that on the other side you are just abused.
Is that happening? Last I heard enrollment in medical programs was still at capacity. Which just goes back to my "don't care about the money" stance, because that seems to have to be the motive if students see whats on the other side yet willfully put themselves through it.
> then potential MDs would stop going through the program seeing that on the other side you are just abused.
Not necessarily, for the same reason that people join fraternities/sororities even knowing that 'hazing' happens: they think the rewards are worth the temporary punishment.
> Which just goes back to my "don't care about the money" stance
I don't think that's a conclusion you can draw from the circumstances, because there's a big payoff for sticking it out through 4-5 years of abuse. Especially in fields like dermatology, the payoff for 4-5 years of abuse could easily be a 7 figure salary.
I would wager a large sum that medical students and interns are well-versed in delayed gratification (I mean, that's sort of how they get to become interns to begin with), so putting up with a few years of hell for a big payoff is something they're quite used to already.
In many ways it's similar to other high-pressure fields with insane initiation periods like investment banking, though deciding to quit in your 2nd year of investment banking involves a lot less risk than deciding to quit in your 2nd year of residency (because of both debt and alternatives).
Then how is the situation bad? It would seem like market equilibrium - students have full knowledge to know the hell they have to go through post graduation before they get a respectable position with a salary worthy of their effort, and apparently the medical system even under such physiologically unhealthy conditions still has all the MD's it needs. If it was ever actually "bad" then potential doctors would stop going to medical school and we would have a doctor shortfall, and the industry would have to stop being so antagonistic of its recruits or better compensate them to regain enrollment.
I was just worried the problem was that students were not aware of what awaited them after 6+ years of bank breaking schooling, and were stuck between a rock and hard place after graduating.
Sorry, just going through I just saw your comment, but I thought you deserved a reply.
> apparently the medical system even under such physiologically unhealthy conditions still has all the MD's it needs
Interns will agree to work 100 hour weeks because they have no alternatives, but I don't think that it's necessarily efficient from an economic standpoint. They have all the MDs they need, sure, but it's highly arguable about whether it's efficient from an economic standpoint. We'd have to compare the cost of medical errors (which is non-negligible) from interns due to fatigue vs. the cost of hiring another intern.
> I was just worried the problem was that students were not aware of what awaited them after 6+ years of bank breaking schooling...
We're talking about basically a decade between when you make the decision to become a doctor and when you receive a MD. Even if you start out on the path to be a MD with perfect intentions, people change heavily over the course of a decade (and especially so at that age).
The grim reality is that even after undergrad (halfway in), if you chose a typical "med school" major you're still in a bit of a bad spot unless you decide to go into research in the life sciences. After graduating med school, your MD qualifies you for 1 thing and comes with the heavy cost of crippling debt. Deciding you don't really like medicine in your 3rd year of med school is incredibly costly and practically unfeasible for most people going through school.
Nobody, not even superhuman-like people, can keep up mental ability doing cognitive demanding work for 6 hours straight. 24 hour shifts sounds downright irresponsible. There must be a significant risk for accidents.
They're often not cognitively demanding. I do 14.5 hr overtime shifts and most of the time I am being paged for 'autopilot' stuff like charting more fluids, reviewing medications, and especially because it's weekends, checking out little niggles that patients start to but nurses about over the weekend and they say they will get a doctor to review.
Between 1-5 times in a shift of this nature I will be required to do something cognitively demanding, most of the rest is patient interaction, reassurance, and basic basic medical stuff that you master in your first month in the job
Would you agree with my doc friend that its mentally like call center work in that everything is extremely heavily scripted and procedural, and flying off on your own wings of fancy is strongly discouraged and detailed reasoning is rarely required?
Its a truly immense set of call center scripts and procedures to memorize and be tested on, but after your 10000th concussion or 10000th wound needing stitches or woman in labor or whatever, its all fairly routine?
My buddy said it to someone outside the field knowing I'm outside the field, to us as customers every interaction is new and mysterious, much like calling into a call center.
My software job is very cognitively interesting, lots of thinking about new things and new ways to do "stuff" and my doc buddy was a bit jealous of my working conditions and working hours.
I had never thought about it as a 'call centre' factory-type operation.
I'd have to say that with my current experience I would disagree.
My job has a huge range of variability. That may be helped by the fact that I rotate I to totally different areas of medicine every few months and will for another year before I start specialising.
Even so, yes it's true (or at least I feel it is) that we are a customer service industry (or at least should be).
Sometimes this is the greatest part of my day.
I know, for example, that for a certain percentage of my patients I will be able to make a huge difference to the perception they have of the healthcare system just by sitting and taking 5 minutes to explain in laymans terms what we are doing.
In my hospital's patient population (mostly white Anglo Saxon Australians, usually slightly older than the national average) this comes across very well because I am a 6 foot 2 100kg white man, so I fit the mould of what they want as a doctor. (Sometimes this results in the patient confiding in me how happy he is that he is talking to a 'real Aussie' - the racism is astounding and very irritating sometimes)
Women have a harder time and many of my female colleagues are regularly assumed to be nurses even after introducing themselves as doctors.
But I digress.
Yes, a lot of my job becomes routine. I have studied for 10 years to be where I am and know huge areas of disease and the pathological basis back and forwards. But that doesn't stop many situations from being fascinating.
When I started med school I was all about the science - I loved it.
Now I have found that a side benefit is (some) of the people and making a difference.
Sometimes I'm too busy, and I can see the ability to get jaded; my (medical) friends and I will often (confidentially) describe some of the horrible situations we have seen; and you need to be able to laugh at times as a coping mechanism.
But I love my job; for the variability; for the characters; for the 1 in 50 patients that totally changes your world view and makes your life richer for having treated them; for the care that is entrusted to me; and for the really top notch people I am surrounded by, who will accept nothing less than excellence from themselves and give their time freely to improve your education and ability
What I've heard is that residency spots are restricted in number by Medicare (who pays hospitals that train residents) under heavy lobbying by the AMA. The rumor is that this is done to artificially restrict the number of MDs in the country thereby raising everyone's salary.
Don't personally know if this is true, but if it is it's shameful, especially given the "physician shortage" crisis. Or maybe crisis should be in quotes.
> What's keeping us from creating more physicians to meet the (obvious) demand?
It takes a lot of money, resources, and existing doctors' time to train a new doctor. One thing that's likely to help a bit is the move to nurse practitioners and physician assistants for much of primary care.
If we had more doctors, it seems that it would also cost less to train more doctors (assuming that more doctors made the average doctor's time less costly). An unfortunate feedback loop there.
the system again drains us of the very thing we enrolled in medical school to be.
And most people who make it through the system seem to want to then reproduce it. Grad schools have some similar problems, but they're less pernicious in terms of hours demanded and debt taken.
I'm a resident: 30hrs every 3-4 days, is standard for residents in years 2 and above, but only in the more demanding services, otherwise usually 12-16hr days.
Q4 is not a walk in the park but it's better than overnights and at least within micu comes with a resident. My point was why say that you are doing 48 hrs shifts?
No 48hr shifts are allowed in residency (out of residency you're SOL), the limit is either 28 or 30hrs ( IIRC its 28hrs + 2hrs for non-patient work or something similar to that, so most people end up doing 30hrs )
Other limits:
- You are not allowed more than 80hrs per week, that is a hard limit and programs will get in trouble if they ask more of you.
- You are required to take 4 days off every 4 week rolling average ( so 1 day off per week, or 2 days off every 2 weeks, etc )
The experience most interns have on day 1 is a massive increase in responsibility and work load as compared to medical school. Whereas most medical students in their 4th year "manage" (under the very close supervision of residents) 2, 3, or maybe 4 patients, on day 1 of intern year they are suddenly expected to be responsible for upwards of 10-12 patients (under supervision, but considerably less supervision than med students). Interns go from spending most of their time studying and learning medicine, to being suddenly, constantly busy with often mind-numbing tasks. We interns joke that we are nothing more than secretaries, doing tasks for our boses all day without time to sit down and think for ourselves, despite the M.D. we just spent years earning. Eventually, we get better at prioritizing, we learn the system, and we learn by doing.
But, early in intern year, we can't prioritize, we don't know the system, frankly we can't even keep which patient is which straight in our heads. But, regardless, we still have n number of tasks to do by the end of the day.
Spending extra time talking to patients isn't part of n. Empathy isn't an item in n. Figuring out a patient's priorities for their health aren't an item. Those are extras.
And to get home on time, after my 12-14 hour shift, all I have to do is my list of n tasks, which is substantial. So, we quickly learned that long conversations with patients are the enemy of getting home on time. And pretty quickly, we start to eliminate those conversations. Then, we figure out that other things patients need, like empathy, a careful history taking and detailed physical exam, family discussions, etc also stand in our way of getting our work done on time.
Eventually, we learn the ability to keep our patient's complex medical problems straight and become much more efficient at getting our work done quickly. So, realizing we have more time, some of us go back and start to do the things that really matter to patients, like those things listed above and in the article. But, we've already learned, or forced by the system to learn, that we can get away with not doing those things, so as soon as we get a little extra busy or are a little extra tired, those are the first things we skip.
Then, suddenly, we start second year and can now be asked to work 24-28 hours straight, and now we have 18-24 patients instead of 10-12 that we are responsible for and the system again drains us of the very thing we enrolled in medical school to be.