I made a mistake

[HarryMTieboutMD]

Harry likes to make provocative idealistic statements about the profession and has mentioned multiple times that training should be more rigorous. The two biggest problems with his ideas:
1. Back in the day doctors made more money and society was much more respectful of doctors (parents used to teach their children to respect doctors, judges, professors, etc). Most medical students/residents would not agree with this explicitly but it certainly is important.
2. A better and more efficient way to have good doctors is to be more selective in the initial screening process (admission to medical school).

I don't quite follow your premise that society's lack of respect for doctors and ostensibly lax screening of applicants precludes an increase in rigor of training. I agree with the former, but how does this at all relate to training rigor?

In the latter case, increased selectivity isn't going to change anything; established US allopathic schools are already selective enough (meaning, they could fill their classes several times over with a equally qualified applicants that they reject for whatever reason). Medicine is learned by seeing a large volume of patients, making judgment calls, and reading. Most med students are very high in risk aversion and harm avoidance coming into residency (because they aren't forced to actually make decisions in med school), and learning to be the decision maker is greatly facilitated by higher patient volumes without an attending hovering over everything

I like the old saying "What is the disadvantage of Q2 call? You only get to see 1/2 the patients!".

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[HarryMTieboutMD]

so basically what you're saying is "oh, you have a family or any other kind of external obligations that aren't medicine? GTFO of the profession."

This is definitely how you attract the best and brightest into the field, ayup, and not people who don't have any better alternatives.

My point is that medicine requires dedication and tough mindedness, and medicine never had any problems attracting talented people long before the incipiency of "humane" work hour rules. And in psychiatry in particular, for too long we have attracted low energy, weak minded people, which I think could be corrected by more rigorous training. Maybe it's from my mindset as a marathon runner/triathlete, but Ipushing myself to always be better (which routinely shows up in my evals) has definitely made me more successful in residency. And if I were in charge of ABPN I would mandate a full year of internal medicine for all psych interns

 

[HarryMTieboutMD]

The biggest problem is that there's nothing that suggests overworking residents makes them better doctors or improves patient care. The same administrative influence that Harry is complaining of is behind these kind of suggestions or policies.

Incidentally, the recent switch back to 24 hour calls for interns was based on the "FIRST" trial. People can read the paper and make their own judgements, but it's pretty astonishing how quick ACGME was in recommending changes based on very questionably inferences that don't even test for the changes ACGME was requesting.

I don't see any issue with the FIRST data- most of it makes sense. I think the overall gestalt is that it sends a message: a d-bag lawyer caused a lot of problems that eventually influenced residency work hours without any data to support it. In response, prospective, physician driven data suggested that in many respects a less restrictive duty hours was more favorable for education, and thus with this, physicians can regain control of how residents are trained

 

[FlowRate]

Incidentally, the recent switch back to 24 hour calls for interns was based on the "FIRST" trial. People can read the paper and make their own judgements, but it's pretty astonishing how quick ACGME was in recommending changes based on very questionably inferences that don't even test for the changes ACGME was requesting.

The p value for more residents in the no-limit trial agreeing with "feeling that your life is overall unsatisfactory" over standard-hours residents was 0.06, and so declared "insignificant."

FIRST was surgeons, the one group of people who can make a decent argument that duty hours are important because they need to see cases (and see cases through instead of leaving during the case.) They're also generally the most hardcore about being OK with long hours in the first place.

Major adverse events are very rare. If you want to show that there's "no difference" between supervised providers (Residents:Interns, Residents:NP's, NP'sA's, etc.), just use death as an endpoint. It's pretty hard to accidentally kill a patient who wasn't otherwise going to die anyway, with all of the EMR protections and when you have an attending watching.

I don't see any issue with the FIRST data- most of it makes sense.

You've got to be kidding. Or so convinced of your opinion that you've become unable to critically read that paper.

 

[deleted736562]

The p value for more residents in the no-limit trial agreeing with "feeling that your life is overall unsatisfactory" over standard-hours residents was 0.06, and so declared "insignificant."

FIRST was surgeons, the one group of people who can make a decent argument that duty hours are important because they need to see cases (and see cases through instead of leaving during the case.) They're also generally the most hardcore about being OK with long hours in the first place.

Major adverse events are very rare. If you want to show that there's "no difference" between supervised providers (Residents:Interns, Residents:NP's, NP'sA's, etc.), just use death as an endpoint. It's pretty hard to accidentally kill a patient who wasn't otherwise going to die anyway, with all of the EMR protections and when you have an attending watching.



You've got to be kidding. Or so convinced of your opinion that you've become unable to critically read that paper.

What's even worse is that the original data in NEJM on which ACGME regulations were based did not even show that the two arms actually spent different amount of time on the service. It was very possible that those in the "flexible" arm simply did not use their flexible "privileges." Yet, NEJM and the authors went out to publish the preliminary data anyway so to give time for ACGME to change its regulations (these are the words of the authors in response to that criticism, not my own)! Talk about lack of professionalism and essentially a freakin joke. The follow up data published very recently last month did show that the flexible arm spent more time, but they only went excess of 16 hours very sporadically i.e they weren't staying every single time they were on call. The second thing, unless I'm missing something, there is quite a difference between given the option to stay longer and utilizing it as you please, and being forced to anyhow because that's your scheduled shift. That among so many issues... The writing in the paper itself was reeking of bias, it's not even funny. In the flyers given to residents, they pretty much made it clear that the purpose is to show what they ended up inferring, which already biases selection. Among many other things.

 

[WingedOx]

My point is that medicine requires dedication and tough mindedness, and medicine never had any problems attracting talented people long before the incipiency of "humane" work hour rules. And in psychiatry in particular, for too long we have attracted low energy, weak minded people, which I think could be corrected by more rigorous training. Maybe it's from my mindset as a marathon runner/triathlete, but Ipushing myself to always be better (which routinely shows up in my evals) has definitely made me more successful in residency. And if I were in charge of ABPN I would mandate a full year of internal medicine for all psych interns

oh c'mon, bro.

 

[nancysinatra]

Sidney Zion is one of the worst humans to ever exist and can continue to rot in hell for what he did to resident education (not our fault his daughter did coke while taking an MAOI).

Is that how you actually feel about patients who come into the ER who have been taking MAOIs and used drugs? That it's "not our fault" and you don't need to know the interactions between MAOIs and demerol (which was part of the case, if you recall?)? And that it's ok if your patient dies who's in that situation because you are off your rocker with fatigue that is induced by New York Hospital's exploitation of resident labor? And you are SURE New York Hospital wasn't exploiting residents? Do you know their history? Really??

 

[nancysinatra]

My point is that medicine requires dedication and tough mindedness, and medicine never had any problems attracting talented people long before the incipiency of "humane" work hour rules. And in psychiatry in particular, for too long we have attracted low energy, weak minded people, which I think could be corrected by more rigorous training. Maybe it's from my mindset as a marathon runner/triathlete, but Ipushing myself to always be better (which routinely shows up in my evals) has definitely made me more successful in residency. And if I were in charge of ABPN I would mandate a full year of internal medicine for all psych interns

Oh please. There have been weaklings in medicine forever. Medicine is as frail a profession as any other. And the thing about resident work hours depriving trainees of the chance to see patients through their illness came from surgery, not psych. Personally I know of no psychiatric illness that requires a 24 hour in person observation period in order to stabilize the patient. It's hard to come up with many psych illnesses that can't be summed up and dispo'd in half an hour, honestly, if you're on your toes.

I've covered call at over a dozen hospitals at this point, and I know of no hospital that requires psych attendings to come in in the middle of the night for new admissions. Academic hospitals pay lip service to the idea by making residents come in - to justify their existence, no doubt.

But in this field, as far as I'm aware, we have three potentially deadly conditions: dementia, alcohol or barbiturate withdrawal, or anorexia nervosa. All of which are heralded in advance because they are chronic conditions. And none of which we actually manage in the acute or end stage ourselves. So what's with the 24 hours thing? Like, what will be accomplished with that? Will we fill out more forms? Is that it? Because I fill out a lot of forms as it is, and did as a resident. And they are not saving lives.

What's funny is, I agree with you that we could benefit from a full year of internal medicine. But that has nothing to do with "toughness" or work hours.

 

[Candidate2017]

What's funny is, I agree with you that we could benefit from a full year of internal medicine. But that has nothing to do with "toughness" or work hours.

It makes perfect sense for psychiatry to be an IM fellowship but I'm glad it's not.

 

[Candidate2017]

And in psychiatry in particular, for too long we have attracted low energy, weak minded people, which I think could be corrected by more rigorous training.

Someone who thinks med students and residents are "low energy, weak minded people" probably shouldn't be in a specialty that treats people with depression, anxiety, substance abuse and PTSD.

 

[HarryMTieboutMD]

Is that how you actually feel about patients who come into the ER who have been taking MAOIs and used drugs? That it's "not our fault" and you don't need to know the interactions between MAOIs and demerol (which was part of the case, if you recall?)? And that it's ok if your patient dies who's in that situation because you are off your rocker with fatigue that is induced by New York Hospital's exploitation of resident labor? And you are SURE New York Hospital wasn't exploiting residents? Do you know their history? Really??

Read the case http://www.nejm.org/doi/full/10.1056/NEJM198803243181209 (guessing her actual long term diagnoses were Briquet's/Borderline and multiple SUDs)

In the 1980s serotonin syndrome was NOT nearly as well known as it is today (Sternbach's criteria came out in 1991, Hunter in 2003). Anyway, she probably came in with serotonergic toxicity (jerks were probably myoclonus and I guess demerol was not infrequently used back then). Also bear in mind the case was staffed with her PCP who had privileges at NYH and recommended admission in the first place (who later lied under oath). Likewise, multiple toxicologists and other experts testified that the interaction of demerol and and an MAOI was not well known. Yes it was in the PDR but in those days people had to go to Index Medicus to look things up, and there were no pharmacy checks on drug drug interactions either.

Obviously there were lapses in care, and the management was peculiar, but her dad's reaction was ridiculous and was only able to toxically manifest because he was a well known writer and attorney- murder charges with absolutely no mens rea?? Really? He will forever be remembered as a pariah and a huge POS.

Oh please. There have been weaklings in medicine forever. Medicine is as frail a profession as any other. And the thing about resident work hours depriving trainees of the chance to see patients through their illness came from surgery, not psych. Personally I know of no psychiatric illness that requires a 24 hour in person observation period in order to stabilize the patient. It's hard to come up with many psych illnesses that can't be summed up and dispo'd in half an hour, honestly, if you're on your toes.

I've covered call at over a dozen hospitals at this point, and I know of no hospital that requires psych attendings to come in in the middle of the night for new admissions. Academic hospitals pay lip service to the idea by making residents come in - to justify their existence, no doubt.

But in this field, as far as I'm aware, we have three potentially deadly conditions: dementia, alcohol or barbiturate withdrawal, or anorexia nervosa. All of which are heralded in advance because they are chronic conditions. And none of which we actually manage in the acute or end stage ourselves. So what's with the 24 hours thing? Like, what will be accomplished with that? Will we fill out more forms? Is that it? Because I fill out a lot of forms as it is, and did as a resident. And they are not saving lives.

What's funny is, I agree with you that we could benefit from a full year of internal medicine. But that has nothing to do with "toughness" or work hours.

You are speaking from the point of view of an attending, where practicing inpatient psychiatry is ingrained into your procedural memory, which for most people comes from A LOT of patient experience (high volume, high acuity) and following them longitudinally (unfortunately in acute units and the current revolving door model this is only about a week) I remember as an intern how frustrating it was admitting a lot of patients overnight and then not being able to see their care through to discharge or conversely, getting signout in the morning on a patient without seeing the rawest pathology. As simplistic as it is, I had to actually see dystonic reactions, possible serotonergic toxicity (see above), possible NMS, PNES, emergent withdrawal, etc to actually learn how to manage them (which I could now do over the phone).

Of course I still was fortunate enough to admit and see a large amount of psychopathology and pushed myself to read read read to the point that now I could probably manage everything by phone, but I felt that night float robbed me of an indispensable experience.

I felt weak and useless as a medical student, but as an intern during my inpatient internal medicine months (where we are treated the same as other internal med interns with high volume/high acuity/SICK) is when I really began to "grow up" as a physician- being able to respond calmly when the nurse calls me when a patient becomes septic, starts bleeding out, desats, etc- this was a really maturing experience, but without ICU and with psych intermixed it felt fragmented and incomplete.

 

[HarryMTieboutMD]

Someone who thinks med students and residents are "low energy, weak minded people" probably shouldn't be in a specialty that treats people with depression, anxiety, substance abuse and PTSD.

You're still a medical student, and thus your opinions/views are meaningless. Your commentary doesn't become insightful until you go through at least intern year. You don't know anything, and July 1 of your intern year, you will be the most dangerous person in the hospital if your ego gets ahold of you. TBH I would slap myself for things I said (and posted on this board) a few years ago.

Here is a quote from one of the legendary psychiatrists from our department who had a very influential voice in American psychiatry in the 20th century:

"It is argued that because it is difficult to measure psychologic phenomena and to characterize psychiatric disturbances... too much should not be expected... But to abdicate the role of constructive criticism is to abandon the field to the tender-minded. The difficulties of the field seem to require just the opposite: a commitment to toughmindedness. Paradoxically toughmindedness is sometimes attacked in the name of humanitarianism. It is asserted, or implied, that a critic who demands "data," who talks about controls, who insists that the burden of proof is on the affirmative reveals thereby that he is not interested in people.... But scientific skepticism is in no way incompatible with compassion for the sick or disabled. In fact, it is the desire to help patients that causes one to be frustrated by the lack of definite knowledge about what really helps and what does not."

 

[Candidate2017]

You're still a medical student, and thus your opinions/views are meaningless. Your commentary doesn't become insightful until you go through at least intern year.

You're still a resident, and thus your opinions/views are meaningless. Your commentary doesn't become insightful until you go through at least being an attending. You don't know anything.

See? We can play this game forever but let's not and just admit you're wrong to label an entire population as "low energy and weak minded."

Why is someone who rants about how tougher they are than other residents because they run marathons giving advice on checking one's ego?

 

[smalltownpsych]

We get a lot of low energy, weak-minded people in psychology too and we have continued pressure from many sides to lower the bar so that we can be more inclusive and understanding. One of my more brilliant professors railed against this trend. He did not believe in pulling punches for the sake of sensitivity. He would often hold up medical training as an exemplar of helping someone learn to function despite high levels of stress. It is scary to think of it going the other way. I am grateful for the tough treatment that he provided me during supervision and preparation for clinical competency exam although it did piss me off a bit at the time. Because of his leadership, I sought out tougher training opportunities and it made me a better psychologist and better able to stand my ground with an EM doc at 2:00 am when we disagree on a plan.

To connect this back to the OP, it is the making mistakes and being pushed to your limits and knowing that the buck stops here when making life or death decisions that makes good doctors. Fortunately, this time, others caught the error, but eventually that won't be the case. One case that haunts me where I made a serious flaw in my risk assessment and treatment plan was seen by a psychiatrist the next day and she didn't catch or appropriately address the extremely elevated risk either, and ultimately the patient jumped off a bridge on the way to our next appointment. I think that might be part of what was meant when saying that medical school students views are meaningless. They haven't had to make those decisions or mistakes yet.

 

[HarryMTieboutMD]

We get a lot of low energy, weak-minded people in psychology too and we have continued pressure from many sides to lower the bar so that we can be more inclusive and understanding. One of my more brilliant professors railed against this trend. He did not believe in pulling punches for the sake of sensitivity. He would often hold up medical training as an exemplar of helping someone learn to function despite high levels of stress. It is scary to think of it going the other way. I am grateful for the tough treatment that he provided me during supervision and preparation for clinical competency exam although it did piss me off a bit at the time. Because of his leadership, I sought out tougher training opportunities and it made me a better psychologist and better able to stand my ground with an EM doc at 2:00 am when we disagree on a plan.

To connect this back to the OP, it is the making mistakes and being pushed to your limits and knowing that the buck stops here when making life or death decisions that makes good doctors. Fortunately, this time, others caught the error, but eventually that won't be the case. One case that haunts me where I made a serious flaw in my risk assessment and treatment plan was seen by a psychiatrist the next day and she didn't catch or appropriately address the extremely elevated risk either, and ultimately the patient jumped off a bridge on the way to our next appointment. I think that might be part of what was meant when saying that medical school students views are meaningless. They haven't had to make those decisions or mistakes yet.

Everything about this is why you are one of my favorite posters on this forum. The truly great therapists who teach us (non psychiatrists) are some of the toughest people I know

 

[HarryMTieboutMD]

You're still a resident, and thus your opinions/views are meaningless. Your commentary doesn't become insightful until you go through at least being an attending. You don't know anything.

See? We can play this game forever but let's not and just admit you're wrong to label an entire population as "low energy and weak minded."

Why is someone who rants about how tougher they are than other residents because they run marathons giving advice on checking one's ego?

*sigh* This is called a false equivalency. Intern year (as watered down as it may be) is when one makes the transition into actually becoming a physician, not only in terms of actually learning how to practice medicine (rather than just fake interest, brownnose, and memorize answers to shelf questions) but really experience the hospital dynamics firsthand. The stereotypes of the different specialties and reputations among different services didn't become that way by chance- there's truth to it. Psychiatry residents tend to be viewed (for good reason) as meek, passive, uncritical, disinterested and straight up awful when off service, etc. For me (and some others in my program) it's kind of innate to be in your face/assertive/critical etc, and the more of this we have, the better

And I do not trivialize an athletic background; in my experience it predicts mental toughness among residents- a drive for competition, the ability to push oneself, learning from failure, etc it's all there. Our dept chair was an NCAA D1 soccer champion, played professionally briefly and for the US national team and is now a world renowned synaptic biologist, a stellar clinician (still; he regularly does clinically oriented conferences with us), and has been chair for 20 years, and he really attributes his drive and success to his athletic background.

 

[WingedOx]

And I do not trivialize an athletic background; in my experience it predicts mental toughness among residents- a drive for competition, the ability to push oneself, learning from failure, etc it's all there. Our dept chair was an NCAA D1 soccer champion, played professionally briefly and for the US national team and is now a world renowned synaptic biologist, a stellar clinician (still; he regularly does clinically oriented conferences with us), and has been chair for 20 years, and he really attributes his drive and success to his athletic background.

Gonna be honest though: You're sounding like Klinsmann.

How'd that work out?

 

[HarryMTieboutMD]

Gonna be honest though: You're sounding like Klinsmann.

How'd that work out?

More like Sepp Herberger "Vor dem Spiel ist nach dem Spiel"

 

[Salpingo]

My point is that medicine requires dedication and tough mindedness, and medicine never had any problems attracting talented people long before the incipiency of "humane" work hour rules. And in psychiatry in particular, for too long we have attracted low energy, weak minded people, which I think could be corrected by more rigorous training. Maybe it's from my mindset as a marathon runner/triathlete, but Ipushing myself to always be better (which routinely shows up in my evals) has definitely made me more successful in residency. And if I were in charge of ABPN I would mandate a full year of internal medicine for all psych interns

These posts would be more amusing if there were fewer resident/medical student suicides. Not that better work hours would reduce psychopathology, but just this lingering, bro-ish mentality that anything less than ortho/Ubermensch status is weakness...

I've posted my feelings here that we shouldn't shy away from clinical encounters, and they're important in our professional development. But this conversation is getting close to Trump-level incendiary trolling, with too many logical fallacies. Just two:

1. You don't retain information if you're tired or burnout. Empirically proven. This is probably the most (maybe only) useful educational info mandated by ACGME, because some of us need colors and graphs to convince us not to work ourselves into the ground.
2. Patients aren't just walking didactics. We're also obligated to help them, not just learn from them. And NO ONE is as effective when they're burnt out or tired (although they often delude themselves into thinking they are).

 

[SmallBird]

For me (and some others in my program) it's kind of innate to be in your face/assertive/critical etc, and the more of this we have, the better.

It sounds like being that way is important for you, and has helped you be effective in a number of ways. Thats great, but there is room enough for other approaches, and whilst I can picture mentors who embody the traits you describe, I have equally valued mentors who were the complete opposite. It is possible to value work life balance, view intern duty hours as inhumane, not enjoy call and still develop excellent clinical skills.

 

[Armadillos]

My point is that medicine requires dedication and tough mindedness, and medicine never had any problems attracting talented people long before the incipiency of "humane" work hour rules. And in psychiatry in particular, for too long we have attracted low energy, weak minded people, which I think could be corrected by more rigorous training. Maybe it's from my mindset as a marathon runner/triathlete, but Ipushing myself to always be better (which routinely shows up in my evals) has definitely made me more successful in residency. And if I were in charge of ABPN I would mandate a full year of internal medicine for all psych interns

Sounds like you feel you have managed to become an excellent (or better) resident within the confines of current duty hours, why do you think it needs to change?

 

[thoffen]

We get a lot of low energy, weak-minded people in psychology too and we have continued pressure from many sides to lower the bar so that we can be more inclusive and understanding. One of my more brilliant professors railed against this trend. He did not believe in pulling punches for the sake of sensitivity. He would often hold up medical training as an exemplar of helping someone learn to function despite high levels of stress. It is scary to think of it going the other way. I am grateful for the tough treatment that he provided me during supervision and preparation for clinical competency exam although it did piss me off a bit at the time. Because of his leadership, I sought out tougher training opportunities and it made me a better psychologist and better able to stand my ground with an EM doc at 2:00 am when we disagree on a plan.

To connect this back to the OP, it is the making mistakes and being pushed to your limits and knowing that the buck stops here when making life or death decisions that makes good doctors. Fortunately, this time, others caught the error, but eventually that won't be the case. One case that haunts me where I made a serious flaw in my risk assessment and treatment plan was seen by a psychiatrist the next day and she didn't catch or appropriately address the extremely elevated risk either, and ultimately the patient jumped off a bridge on the way to our next appointment. I think that might be part of what was meant when saying that medical school students views are meaningless. They haven't had to make those decisions or mistakes yet.

It's a false dichotomy that you either pull punches and cater to the sensitivities of the low-energy and weak-minded or develop clinical competency by intense and grueling clinical training.

We can provide people with significant rigor in their clinical experience to develop clinical competency without being inhumane, and putting a spotlight on the desire to be more humane, inclusive, understanding, etc. does not obligate you to sacrifice attention to clinical deficiencies for the sake of fairness. It's not easy, but so often the ideal is sacrificed thinking it important to choose between compassion or duty.

 

[smalltownpsych]

It's a false dichotomy that you either pull punches and cater to the sensitivities of the low-energy and weak-minded or develop clinical competency by intense and grueling clinical training.

We can provide people with significant rigor in their clinical experience to develop clinical competency without being inhumane, and putting a spotlight on the desire to be more humane, inclusive, understanding, etc. does not obligate you to sacrifice attention to clinical deficiencies for the sake of fairness. It's not easy, but so often the ideal is sacrificed thinking it important to choose between compassion or duty.

I agree with the false dichotomy and I have seen either extreme used as a rationalization for a poor training environment. Like many things in psychological and interpersonal functioning, the problem tends to lies at the extremes. For example, I did some research on unhealthy or even harmful group psychotherapy dynamics and in general there were two types of leaders or facilitators that were harmful. At one end were the laissez-faire leaders and at the other were the authoritarian types of leaders. So I agree that it is a false dichotomy because I do strive for the middle myself and tend to challenge either extreme. I am not sure about medical training, but I do think psychology tends to lean a bit too much on the soft and understanding side.