Some posts on this thread highlight a huge problem with this (my) generation of trainees... medicine is NOT a 9-5 job. You get there early, and stay until the job is done. My response to people complaining about being in the hospital too much/sleep deprivation on 24+ hour call is man/woman up! Seriously, the only way to truly learn about a disease and its clinical course is to follow it longitudinally. I actually think medicine had it right with the original idea of house staff living in the hospital for at least one year. That way, you get the entire picture. I hate getting signout in the AM having missed a huge event on one of my patients overnight. At the same time, some of my key learning moments have been on cross cover/night pages from nurses about unforeseen events happening to patients... but it would be even better if I were able to follow them up daily. The abuse that happened in the old days (Halsted to House of God, etc) would have probably abated irrespective of actual work hours, though I have learned (and grown) exponentially from tough attendings. There is always time for reading, and it's so easy with uptodate/pubmed at our fingertips. Think about the old days when residents had to go to the library to look up articles and fight over textbooks! While I am learning a lot and overall loving residency, I think lawyers (read: Sidney Zion) have officially screwed us over
It's important to clarify what we're talking about. It's one thing to work hard and put in long hours as a duty to patient care. It's quite another to be working more hours and taking more call for the sake of working more hours and taking more call. Typically more work is created not out of necessity but rather as a result of inefficiency and apathy. This will traditionally fall on residents. However, our culture, perhaps as some type of maladaptive defense mechanism, embraces and supports this under the guise of education and being a "necessity" of training (belief that whatever doesn't kill you will make you stronger). Now, there's not necessarily a problem with this point of view. It becomes problematic when work or tasks are being made hard simply for the sake of being hard. Or when answers to simplify work are dismissed for the sake of having "hard" training as we've become conditioned to associate that with great learning.
What makes physician training unique, which is obviously not secret or very complicated, is the varied diversity of experiences. This is typically accomplished through volume. Volume is often accompanied by long hours and time in the hospital. One of the biggest problems with this, however, is the tendency for so many in medicine to conflate what's actually happening. We begin not just treating, but presupposing, hours at work and time in the hospital is the independent variable in the equation. So enter someone (anyone) with a cheap labor force below them and you can package just about anything wrapped in the pretty wrapping paper of hours and hospital time and hand it out in the name of education and many will gladly receive it.
To further demonstrate, take a look at 'prestigious programs' and 'sweatshop programs' that are discussed. Look at how they describe their call. My hypothesis is that if you go to a name brand place and get worn down with call, you're much more likely to feel validated by the fact that you're at a strong place and this is part of that rigorous training that's going to transform you into a skilled clinician. If you're at a relatively unremarkable program, you're probably a lot more likely to feel you're just being exploited as nobody is running around reassuring you how "Random U's clinical training is top notch!" The difference in my estimation between "hard, solid clinical training" and "sweatshop" is the name of the program. Then you have the opposite effect, where we see rather average programs that have a great lifestyle then get labeled as being "wonderful" or "hidden gems" and talk about how the clinical training is great. Kind of like people justifying their purchase of Playboy for the articles. My example on this is San Mateo. Everyone knows this is a lifestyle program. But we also talk about how great the clinical training is and pretend we don't like it just because they don't have any call. If this program had an average work schedule, would anybody care? This isn't a knock to San Mateo because I'm sure it's a fine program (much like many others), but seriously.
I advocate for getting good exposure to a number of different settings and subspecialities. I also advocate factoring in lifestyle and call as a primary discriminating point between programs. I believe it is more wise to pick up the volume in a moonlighting setting (and you can get more diverse settings by doing so) where you'll actually get paid. Someone above mentioned that they really felt the learned a lot on call. I think it's important and I hope the tone of my post doesn't simply come across as "call = bad." The problem is that you maximize the benefit of what's learned on call rather quickly and your benefit plateaus. Sure, you'll learn and know more if your fourth year included q14 24 hour call. There's no arguing that. But how much more? At what expense? Is there any way you could gain an equivocal amount of information/experience in
drastically less time and with less personal cost? Of course, our training usually prohibits this kind of thinking and is viewed as heretical apostasy as it blasphemes against the established docrtines of our day. The argument is always made that moonlighting is not the same as call because it is not supervised, despite the fact that the supervision (as demonstrated in bartleby's post) is so limited as to almost be in-name-only. However, because call is call, it is funneled under the magical and mystical umbrella of "education and training" and therefore caries more value and makes it inherently different, apparently.
Regarding the nightfloat things, it does depend on where you're at. The way we have it, 6 months of the year you do nightfloat (though only covered by interns) you also have weekend calls peppered in. If you were to be able to get it all out of the way without other call responsibilities, I may favor this. It really makes it tough because most places you're comparing apples and car batteries. Call can also vary significantly, from taking home calls about trazodone and Tylenol to seeing every single person who whispers any kind of mental health issue, or anyone the ED resident thinks may have whispered something about mental health.
When the ER pages you at 3:30 am because they want you to "come take a look at" a guy with no mental health history who came in from a bar 15 hours ago with a BAL of 400 after he fell and suffered head trauma, but apparently may have told EMS he wanted to die, but is now sober and wants to go home (and is not on any legal hold), and denies any desire or history of self-harm, you're not going to get much benefit no matter how many times you're repeatedly seeing this scenario. Naturally, you'll have others on the opposite end of the spectrum who will want to pursue a legal hold on this guy because "what if he gets drunk and acts crazy again?" So you can always pursue a legal hold to keep a patient and perhaps give them a detox that they don't want and save the world because, hey, at least on paper you can say you tried everything for this guy! I don't think you'd find many people who are too bent out of shape about having to admit legitimate manic/psychotic patients or the legitimately depressed. I think you see the burnout from the collosal waste of time and resources being utilized from the mistaken notion that psychiatric treatment addresses things that it does not. This notion comes from society's faulty beliefs about our field that we continue to reinforce out of fear of litigation
However, regarding call, if you're at a place like NYU where you've got a dedicated ER and seeing a very wide range of legitimate pathology at all hours and you've got an actual attending on-site to lay eyes on patients and teach you when needed, I could see how this would be a very valuable experience. This isn't what happens at the other 98% of programs, though (and I'm only assuming this would resemble what their ER looks like).
That's about as much wind as I've got. I'll make my next lengthy post in another year or two. Be sure and stick around.
