Is residency really that crazy? It seems so illogical

[TheNewGuy8]

I don't understand residency. I certainly understand getting experience. But I don't understand the (at least image of) treating our future healthcare providers in the most unhealthy ways imaginable.

Anyway - I'm finding that as I look at career paths the biggest thing standing between a clear decision is the looming spectre of residency. It will fall when I'm about 34 and thats when I' hope i'll be getting around to starting a family. I don't want to be absent in my kids lives and this is cause for concern.

I want a life/work balance. But I also want to practice primary care medicine.

Are there resources where I can learn more about residency? Are there programs that are more hospitable than others? Or does everyone work 80-110 hours/week?

---

Members don't see this ad.

 

[MCAT guy]

I don't understand residency. I certainly understand getting experience. But I don't understand the (at least image of) treating our future healthcare providers in the most unhealthy ways imaginable.

Anyway - I'm finding that as I look at career paths the biggest thing standing between a clear decision is the looming spectre of residency. It will fall when I'm about 34 and thats when I' hope i'll be getting around to starting a family. I don't want to be absent in my kids lives and this is cause for concern.

I want a life/work balance. But I also want to practice primary care medicine.

Are there resources where I can learn more about residency? Are there programs that are more hospitable than others? Or does everyone work 80-110 hours/week?

No one works 110 hours a week in residency right now.

Yes, many work 80 hours.

Yes, you will have to sacrifice time.

Residency is tough but part of the game.

Primary care isn't going to be a killer residency, definitely not 100 hours. Do some reading on this site, also google is your friend. A few hours and all your curiosity should be satisfied.

 

[Quik]

In my humble opinion, if you want to go into primary care, and not sacrifice nearly a decade of your life, you would be wise to go the PA route. Two years and done, and your career options are pretty much limitless (in PC anyway). In my mind, there just isn't enough distinction in either pay or practice between the two to warrant such sacrifice for the MD/DO.

 

[eablackwell]

One of the docs at Miami Children's talked to us about residency changes when I was there for my 2nd look weekend. The hour limits it changed to seem very doable.

As for 80 hr work weeks, I worked 80 hrs a week (2 ft jobs) for about 3 months to pay bills back in the day. At least if I work that much in residency I'll be doing something I chose to do and looking forward to a brighter future.

 

[Pons Asinorum]

Any job of similar professional stature will have its periods of intense work. Call one of your friends from back in the day who slipped into that junior analyst position with an investment bank and ask them how many hours they worked for those first four-five years. It was a hell of a lot more than 80 hours a week. Same with big law, consulting, project-driven engineering, etc. Smart people have figured out how to make 80 hour weeks work for a long time; you'll do the same.

 

[MCAT guy]

Any job of similar professional stature will have its periods of intense work. Call one of your friends from back in the day who slipped into that junior analyst position with an investment bank and ask them how many hours they worked for those first four-five years. It was a hell of a lot more than 80 hours a week. Same with big law, consulting, project-driven engineering, etc. Smart people have figured out how to make 80 hour weeks work for a long time; you'll do the same.

Agreed. I almost went this route with my response. I think people who complain haven't worked or been around other fields. Medicine isn't the only demanding field.

And as Quik said, I agree. Go PA for primary care. Mid-levels are scary to me so I would never specialize in family practice or primary care. Mid-levels will take over PC with 20 years.

 

[FrkyBgStok]

as a slight tangent, but still on topic, whenever I work at the hospital, I will see the surg residents sitting in the ER for much of the night. i don't see them throughout the whole night and i am sure they have their work, but I pictured the 80 work week would consist of a pretty full schedule for every minute of the day. is it not like that?

 

[Pons Asinorum]

...I will see the surg residents sitting in the ER for much of the night. i don't see them throughout the whole night and i am sure they have their work...

Do you work at Seattle Grace?

 

[BPlaysItCool]

This issue seems to be making the rounds. I think a lot of us are concerned with it. I think many of us also buy into the bravado. Semper Fi. All hail the chief. The queen. Whoever, whatever.

It's only been in recent years that mentioning it in hushed tones wouldn't get you strung up in the town square.

I'll hold down the opposing view. Residency is daunting. And notably highly variable. Surgeons, man they go at it hard. Those older ones are pissed about that weak 80 hours. And you better believe some places scoff at keeping accurate tabs. And many residents feel that they do need these types of hours to train effectively. Who am I to disagree?

But it goes into my career calculus heavily. And FM, peds, IM, and OB are not easy residencies. ED for that matter might be shift work but show me someone who works harder for that period of time. It's a full on sprint at most ED's. Primary care might be easier to match into and might be couple notches easier than surgery in terms of hours/rigor of training. But a bustling 70 hours a week aint no cake walk. Are there all sorts of crazy out there? 80 hour/week business people or lawyers? Sure. But does that make it sane as the OP is inquiring about?

Not to me. I feel it is mental and physical degradation. Outright stressed out freak / slob-inducing mania. And I don't think it's even necessary for most fields. I have a lot of respect Surgery and how much one needs to know for and be able to execute so I reserve opinion in any absolute sense. Some in IM are convinced you have to follow the patient for 2-3 days at a time to learn properly. Plausible. But iffy. To me at least.

There are fields that value a more rested ballanced mental environment. Some fields in fact require that attribute. Anyone ever seen an exhausted resident being paged constantly and trying to work from a patient's or caretakers perspective? I have. The results are horrible. Can they get the job done? I suppose. But what if it's a better question as to how they get the job done? I'm interested in any field that asks that question. Even tangentially. They're out there. On the periphery of the hysteria that dominates the medical student's influences.

 

[EdLongshanks]

Any job of similar professional stature will have its periods of intense work. Call one of your friends from back in the day who slipped into that junior analyst position with an investment bank and ask them how many hours they worked for those first four-five years. It was a hell of a lot more than 80 hours a week. Same with big law, consulting, project-driven engineering, etc. Smart people have figured out how to make 80 hour weeks work for a long time; you'll do the same.

Even last year I was putting in 80/90 hour weeks as a software tech analyst.

The key is the difficulty of the work during this 80 hour week. Is this serious, sweat pouring off of you, running from patient room to patient room, getting histories, doing admissions, attending rounds --- or is this running for 6 hours with some sitting and waiting time in between?

 

[Law2Doc]

as a slight tangent, but still on topic, whenever I work at the hospital, I will see the surg residents sitting in the ER for much of the night. i don't see them throughout the whole night and i am sure they have their work, but I pictured the 80 work week would consist of a pretty full schedule for every minute of the day. is it not like that?

I'll shed some light on this. There will be very busy days and not so busy days. For example when you are a surgery resident on call in the wards (ie not working in the ICU), your job generally is to tend to the pre and post-surgery patients of the team, see potential new admissions, and see inpatient consults. There will be times when you are flat out running from room to room because all of your charges are trying to die on you and everybody is pulling out their lines and the nurses keep calling about patients in more pain than they ought to be experiencing. At the same time your pager may be going off nonstop for potential ER admissions and medicine team consults. You may realize 10 hours into the night that you haven't even had a chance to hit the rest room yet. On other days, by contrast, where the team's census is low, not a ton of people coming through the ED, and all the patients seem stable and are tucked away for the night, you may find yourself with free time to read, or watch Hulu, etc. There isn't any real rhyme or reason to it. Folks who always seem to have bad luck and have rough call nights are said to have a "black cloud", others seem to always luck out with easy nights and are said to have a "white cloud". The norm is probably someplace in the middle. But I wouldn't get fooled by the snapshot view of residents you may have gotten. You probably caught them at a few good moments. But when it rains on them, it can really pour.

 

[Law2Doc]

...

I'll hold down the opposing view. Residency is daunting. And notably highly variable. Surgeons, man they go at it hard. Those older ones are pissed about that weak 80 hours. And you better believe some places scoff at keeping accurate tabs. And many residents feel that they do need these types of hours to train effectively. Who am I to disagree?
...

Although it's not really your thesis, I guess I would echo the bolded aspect. It's not really about bravado or the sentiment of the old guard. While in med school that is what it seems like -- nobody likes to work crazy long hours and there are lots of things in your life you'd rather be doing than hanging out at the hospital, so the folks that seem to be so gung ho get met with a bit of disdain. But things will change -- you are going to realize as you get deeper into residency that it's going to be your ***** on the line very very shortly, and you are going to want to learn as much as you can. You will start to get some angst that you have so much to learn, and so little time. You only get a relatively short period of time to train with the residency safety net. And that's true no matter what specialty we are talking about, be it surgery, or FM. Thus you are going to see the senior residents on occasion stay on past their duty hour limits for the opportunity to jump into that once in a lifetime type case, or into the case where the attending is actually going to let them do the whole thing, or stay to see/do another procedure, or to sit in on a meeting discussing an unusual diagnosis. Yeah, you have other things you'd rather be doing. But you also feel an increasing need to invest more into your training before it's over. And believe me, it flies by pretty fast, particularly when you are working long hours.

 

[MCAT guy]

Although it's not really your thesis, I guess I would echo the bolded aspect. It's not really about bravado or the sentiment of the old guard. While in med school that is what it seems like -- nobody likes to work crazy long hours and there are lots of things in your life you'd rather be doing than hanging out at the hospital, so the folks that seem to be so gung ho get met with a bit of disdain. But things will change -- you are going to realize as you get deeper into residency that it's going to be your ***** on the line very very shortly, and you are going to want to learn as much as you can. You will start to get some angst that you have so much to learn, and so little time. You only get a relatively short period of time to train with the residency safety net. And that's true no matter what specialty we are talking about, be it surgery, or FM. Thus you are going to see the senior residents on occasion stay on past their duty hour limits for the opportunity to jump into that once in a lifetime type case, or into the case where the attending is actually going to let them do the whole thing, or stay to see/do another procedure, or to sit in on a meeting discussing an unusual diagnosis. Yeah, you have other things you'd rather be doing. But you also feel an increasing need to invest more into your training before it's over. And believe me, it flies by pretty fast, particularly when you are working long hours.

Responding to your point.

Then extend residency a year or two. Problem solved.

More money VS better training? I gave up on $ a while ago.

 

[MeowMix]

Then extend residency a year or two. Problem solved.

It all seems logical, but you have not yet experienced $160,000 loans and a $50,000 salary. Extending the residency is just extending the financial misery.

 

[BPlaysItCool]

Although it's not really your thesis, I guess I would echo the bolded aspect. It's not really about bravado or the sentiment of the old guard. While in med school that is what it seems like -- nobody likes to work crazy long hours and there are lots of things in your life you'd rather be doing than hanging out at the hospital, so the folks that seem to be so gung ho get met with a bit of disdain. But things will change -- you are going to realize as you get deeper into residency that it's going to be your ***** on the line very very shortly, and you are going to want to learn as much as you can. You will start to get some angst that you have so much to learn, and so little time. You only get a relatively short period of time to train with the residency safety net. And that's true no matter what specialty we are talking about, be it surgery, or FM. Thus you are going to see the senior residents on occasion stay on past their duty hour limits for the opportunity to jump into that once in a lifetime type case, or into the case where the attending is actually going to let them do the whole thing, or stay to see/do another procedure, or to sit in on a meeting discussing an unusual diagnosis. Yeah, you have other things you'd rather be doing. But you also feel an increasing need to invest more into your training before it's over. And believe me, it flies by pretty fast, particularly when you are working long hours.

I suppose everyone makes individual assessments about what would make them the best they can be at any point along this course of training.

It's my thesis that this is often not what the physician themselves thinks is correct. And that an elaborate facade has been culturally constructed. Such that the angst you speak of is our maladapted baseline of existence when it's said and done.

Because there's just no limit to fanaticism when you follow your thesis to it's logical conclusion.

There are those around us now in the early years that are on a clear trajectory for bat-****-crazy. And the funny thing is. They're normal. They're the best of the best. And they never say no to the external "you're not good enough."

I'm comfortable with uncertainty. I'm looking for modes of expression in medicine that don't stipulate monk-like careerist religiosity. I guess I'll never see you at the top.

I want to be competent. Very much so. But I want to be human. To be sane. And well-developed in areas outside of medicine. Relationships with other humanoids comes to mind.

To be continued....years from now.....when I can sit in your shoes and either agree with you. Or me.

 

[MCAT guy]

It all seems logical, but you have not yet experienced $160,000 loans and a $50,000 salary. Extending the residency is just extending the financial misery.

Well, they now have IBR. So 10 years of payments at 15%(income) and debt wipes out if you work non-profit (like a university).

I think with IBR it won't matter too much when I flip to an attending.

 

[Law2Doc]

Responding to your point.

Then extend residency a year or two. Problem solved.

More money VS better training? I gave up on $ a while ago.

Some specialties are likely to increase the residency track by a year in light of duty hour changes. But for the most part residents aren't in favor of adding years to the ordeal. You would find yourself alone in this suggestion. Most view residency duration like removing a bandaid -- we'd rather it be one quick rip rather than slow and painful. Not something you really want to drag out, even though you need to make sure you get enough training. It's not about the money -- part of the reason some of the negatives of residency are tolerable is because it is so finite.

 

[MCAT guy]

Some specialties are likely to increase the residency track by a year in light of duty hour changes. But for the most part residents aren't in favor of adding years to the ordeal. You would find yourself alone in this suggestion. Most view residency duration like removing a bandaid -- we'd rather it be one quick rip rather than slow and painful. Not something you really want to drag out, even though you need to make sure you get enough training. It's not about the money -- part of the reason some of the negatives of residency are tolerable is because it is so finite.

Well, why not make residency more bearable?

It's just like studying. I'd rather study a good amount everyday and never in excess, rather than going bonkers in the final week and hoping the whole process would just end.

But hey, I'm just a naive new medical student. What do I know.

 

[MCAT guy]

The economic structure in terms of labor that residents provide to hospitals and the conservative culture in terms of resistance to change that is the nature of medicine, make it changes to the system of training medical residents inherently difficult to change.

Wait. They don't want to keep cheap labor? Am I missing something?

Despite the surface view that residency is primarily a process to train young doctors, the impact upon individuals who are residents is not a major driving force in how these programs are structured. Impact to patients (both medically and legally), the labor needed by hospitals, the indoctrination of information and culture to the medical specialty, and, above all, the funding for residency slots by the government, are the main driving forces. Making it bearable to residents seem to be lost in all this.

Hmmm. Funding for extra years for residents would not cause health care costs to increase. Maybe to the government but not to health care in general. And no one said that the impact upon the individuals should be the "driving force." People on this site always try to make a stance seem extreme when it isn't.

Comment: Let's not work 30 hours because people are driving home and wrecking their car. Lets not work 90 hours a week so we can sleep or spend time with family or work out.

Response: Residency isn't about making you happy.

???

I don't see how asking for reasonable requests has somehow turned into a desire for a resident's schedule to be the driving force of decision making. Keeping the patient healthy is the driving force but there is also some amount of reasonableness that can be added to the mix. It's funny because in European countries they cap doctors at what, 45 hours a week? And they still somehow manage to have a healthier nation than America.

Only in the medical field will a person who desires to work ~70 hours a week be accused on wanting plush work conditions and not thinking about their patients. Sorry if I like to do things like work out and spend time with family/friends.

 

[Law2Doc]

... It's funny because in European countries they cap doctors at what, 45 hours a week? And they still somehow manage to have a healthier nation than America....

Not so funny -- apples and oranges. Folks training in Europe "graduate" into a more foregiving landscape with predominantly socialized medicine and a less litigious society -- patient expectations are very different and you have more leeway to continue learning on the job. Most Europeans I have talked to who emigrated here post-training felt that it takes quite a bit of time for them to get to the same level of training at 45 hours/week that US residents get to after 80+ (although most feel that eventually they get to the equivalent end point).

Additionally, their patient population in Europe is about as dissimilar to the US as you are going to find due to a variety of socio-economic and demographic reasons largely unrelated to healthcare. We are a more obese, more hypertensive, more diabetic, more heart diseased, more drug using and more gun-playing society, with more HIV and many other ailments than you are going to find in Europe, and as a results the challenges are very different. On top of that, many folks in the US don't have good access to preventative healthcare or meds, which means we see all these folks later in disease progression than you would in Europe, and we don't ration healthcare like you do in Europe, meaning even the borderline case gets an MRI or dialysis, which drives up healthcare costs. And we practice defensive medicine in a way foreign to Europe, meaning every person gets the million dollar workup. If you have access to care in the US, you get better care, but the folks who don't have access or who are unhealthy for reasons other than access, drive up the costs. And a larger portion expect immediate care (not something you get in a socialized system) and many sue afterwards for things that are shrugged off in a socialized system.

So yeah, they have a healthier nation than America but that's not really going to be an argument for more or less training or residents -- it's an argument for the ongoing dialogue for healthcare reform, tort reform, immigration reform, drug enforcement reform, addressing national nutrition, gun control, and so on. So I think you really do nothing but obscure the issue when you try to bring what they do in Europe to a discussion on US residency. What works in Europe in terms of training will only be applicable in Europe and nations facing similar demographics and societal issues, and has no place in this discussion. Just my two cents.

 

[Law2Doc]

Wait. They don't want to keep cheap labor? Am I missing something?
...

As for "cheap labor", yeah you are missing something. Residents are a big COST to hospitals. They require higher insurance premiums, training costs, administrative costs, and a variety of other expenses. They slow things down, make costly mistakes, require additional administrative personnel (GME offices, whistleblower lines, etc), and make the hospital jump through a variety of time consuming hoops. It's only because the government nicely subsidizes each resident on top of whatever they generate as physicians that hospitals take them on in the numbers they do. Hospitals by and large don't self fund unfunded positions, so this should tell you that residents are not money makers in and of themselves without the six digits a hospital gets from Medicare for each. Debatably the more senior residents start adding actual value and become a windfall to the hospitals. But you are kidding yourself if you think of them as cheap labor. They are really just access to a nice check from the government for a role that otherwise could be filled more efficiently by an ancillary professional, and anything else they generate is just gravy.

 

[MCAT guy]

Not so funny -- apples and oranges. Folks training in Europe "graduate" into a more foregiving landscape with predominantly socialized medicine and a less litigious society -- patient expectations are very different and you have more leeway to continue learning on the job. Most Europeans I have talked to who emigrated here post-training felt that it takes quite a bit of time for them to get to the same level of training at 45 hours/week that US residents get to after 80+ (although most feel that eventually they get to the equivalent end point).

Additionally, their patient population in Europe is about as dissimilar to the US as you are going to find due to a variety of socio-economic and demographic reasons largely unrelated to healthcare. We are a more obese, more hypertensive, more diabetic, more heart diseased, more drug using and more gun-playing society, with more HIV and many other ailments than you are going to find in Europe, and as a results the challenges are very different. On top of that, many folks in the US don't have good access to preventative healthcare or meds, which means we see all these folks later in disease progression than you would in Europe, and we don't ration healthcare like you do in Europe, meaning even the borderline case gets an MRI or dialysis, which drives up healthcare costs. And we practice defensive medicine in a way foreign to Europe, meaning every person gets the million dollar workup. If you have access to care in the US, you get better care, but the folks who don't have access or who are unhealthy for reasons other than access, drive up the costs. And a larger portion expect immediate care (not something you get in a socialized system) and many sue afterwards for things that are shrugged off in a socialized system.

So yeah, they have a healthier nation than America but that's not really going to be an argument for more or less training or residents -- it's an argument for the ongoing dialogue for healthcare reform, tort reform, immigration reform, drug enforcement reform, addressing national nutrition, gun control, and so on. So I think you really do nothing but obscure the issue when you try to bring what they do in Europe to a discussion on US residency. What works in Europe in terms of training will only be applicable in Europe and nations facing similar demographics and societal issues, and has no place in this discussion. Just my two cents.

I think it has a place in the discussion. I preface this with the admittance that you likely know much more about this topic than I do. But I still think the ideas I mention are worth consideration.

I hear this argument all the time, that we have worse patients than Europe but much better health care. Guns and immigration don't cause obesity, diabetes, and hypertension. If we weren't eating ourselves to death the gun totting, immigration and drug enforcement arguments would hold more weight.

Isn't the purpose of health care to get the nation healthier? Isn't prevention just as important as treatment of chronic diseases due to lifestyle choices? Saying our patients are worse is a poor excuse. We have every ability and resource to have patients just as healthy.

Maybe they have better patients because they don't have philosophies like, "get it done as fast as possible, forget sleep and health while you accomplish your goal." That idea which underlies our medical training is pervasive throughout America. We can all agree the way residents are trained is poor for their health (30+ hour shifts, 80+ hr weeks, no time for exercise or family/friends) BUT it accomplishes a goal faster. Is it any wonder that people want to eat faster unhealthier food or not go exercise to save time. They want to accomplish their goals too and if they can do it faster, why pay attention to their health. Yes, we see patients in later progressions of their diseases. It only follows suit with the rest of this mentality. Go full speed until you burn out. If physicians don't prioritize their health how do they convince their patients too? Sleeping 7 hours a day is good for you. Limiting work to around 70 hrs would allow time to relax, exercise or socialize which improves your health.

It's no wonder we can't convince Americans to be diligent and take care of their health. Our whole philosophy is rooted on accomplishing things at the expense of whatever. And as many are saying, "Health or lifestyle of the individual (Residents/whoever) is of little concern. Accomplishing the goal is most important." That attitude has spread like a virus across our great states.

 

[loik22]

And a larger portion expect immediate care (not something you get in a socialized system)

If you need immediate care, you will get it in Western Europe. I am just as, if not more, comfortable getting care on the other side of the Atlantic.

BTW, I do not know how training is done in all the EU countries, as each as its peculiarities, but AFAIK, training is much longer for med school. In many countries, you get straight into med school out of high school, and spend 6-8 years, before starting residency. And those I know who went through it spent more than 45 hours/week.

I agree fully with the different patient mentality remark.

 

[Law2Doc]

...Guns and immigration don't cause obesity, diabetes, and hypertension. If we weren't eating ourselves to death the gun totting, immigration and drug enforcement arguments would hold more weight.
...

Um no, you missed my point. We have more gunshot wounds than in Europe. We have more parasitic diseases, HIV, syphilis in the US due to immigration than Europe. We have more drug related health problems than Europe. PLUS we have more hypertension, diabetes, obesity. It's a bad combo. Lots of things we have that they don't have to deal with means their patient population is already healthier even before you start talking about healthcare. And that's why it's a silly argument. It's like asking why one person can cure a strep throat but another is having so much trouble curing AIDS. It's because they aren't the same at all.

 

[MCAT guy]

Um no, you missed my point. We have more gunshot wounds than in Europe. We have more parasitic diseases, HIV, syphilis in the US due to immigration than Europe. We have more drug related health problems than Europe. PLUS we have more hypertension, diabetes, obesity. It's a bad combo. Lots of things we have that they don't have to deal with means their patient population is already healthier even before you start talking about healthcare. And that's why it's a silly argument. It's like asking why one person can cure a strep throat but another is having so much trouble curing AIDS. It's because they aren't the same at all.

Um... I think you missed my point. Just because our patient population is worse doesn't explain our disregard for health issues. Instead of comparing AIDS with strep throat, lets compare our nation's obesity to another nation's obesity. Fair comparison.

Below is a list from a few years ago and has nothing to do with:

• gunshot wounds
• parasitic diseases
• HIV
• syphilis
• drug related health problems

OBESITY RANKINGS

• Rank Countries Amount
• # 1 United States: 30.6%
• # 2 Mexico: 24.2%
• # 3 United Kingdom: 23%
• # 4 Slovakia: 22.4%
• # 5 Greece: 21.9%
• # 6 Australia: 21.7%
• # 7 New Zealand: 20.9%
• # 8 Hungary: 18.8%
• # 9 Luxembourg: 18.4%
• # 10 Czech Republic: 14.8%
• # 11 Canada: 14.3%
• # 12 Spain: 13.1%
• # 13 Ireland: 13%
• # 14 Germany: 12.9%
• # 15 Portugal: 12.8%
• # 15 Finland: 12.8%
• # 17 Iceland: 12.4%
• # 18 Turkey: 12%
• # 19 Belgium: 11.7%
• # 20 Netherlands: 10%
• # 21 Sweden: 9.7%
• # 22 Denmark: 9.5%
• # 23 France: 9.4%
• # 24 Austria: 9.1%
• # 25 Italy: 8.5%
• # 26 Norway: 8.3%
• # 27 Switzerland: 7.7%
• # 28 Japan: 3.2%
• # 28 Korea, South: 3.2%

So yes, while we can say we have a bad combo that doesn't excuse our negligence as a nation. Our nation's health is POOR even in areas we have control over. My point. In other words, even if you disregard all the conditions due to the factors you mention above, we are still in poor health as a nation.

We have 3x more obesity than France. Significant.

 

[Law2Doc]

...
So yes, while we can say we have a bad combo that doesn't excuse our negligence as a nation. ...

Sure, but it does excuse our futility as healthcare providers. As a doctor I have no power over the nation. That was MY point above. The problems aren't predominantly healthcare problems. They are socioeconomic problems. As a nation that is something that perhaps can be addressed. But as a healthcare professional, you aren't going to be fixing those. So go ahead and write your congressman if you want. But this really has no business in a residency discussion, and is the reason I suggested above that bringing foreign nations into the discussion only serves to obscure.

 

[Law2Doc]

...
Below is a list from a few years ago and has nothing to do with:

• gunshot wounds
• parasitic diseases
• HIV
• syphilis
• drug related health problems

...

Again, I think I already said above that these aren't related to obesity. They are US healthcare problems we have IN ADDITION TO obesity. There are many many many reasons the US healthcare issues are harder to address than Europe. That's my point. Europe isn't the same animal as the US, so you are kidding yourself if you think suggesting Europeans work X hours and get the job done has any relevance to a discussion of US hours.


Anyhow, I think we've run this debate into the ground and a bit off track. If anyone has specific questions about residency, I am happy to try and answer.

 

[MCAT guy]

Agree to disagree I guess.

 

[Skialta]

Back more to the issue of the US system as it is. I am a surgery resident so this is from my perspective and not necessarily any of the other non-surgical specialties. In my mind the problem with just shortening the hours per week is that you really miss out on following a disease through the course of treatment from admission/diagnosis to the treatment (operation) and general care of the patient. Example: say it is a 45 hour week and now there is no such thing as call due to hours so I am on a 9 hour shift schedule (9hrs 5 days wk = 45hr) I admit a patient with say a contained rupture of a splenic artery aneurysm in my 8th hour of my shift. So, by the time I stabilize the patient to take them to the OR I am now forced to go home. Another resident does the case. I would be lucky to ever see this case as a resident and now I am forced to walk away. I can't really see how this is going to benefit me in the future because I got to go home and play xbox or play with my kid instead of actually managing a rare disease. The next time I see the patient they are stable in the ICU. Under this model your care of the patient is very spotty, a lot can happen very quickly to patients and if you are only there 9 hours 5 days a week you are missing a lot. My further complaint is that once you leave residency there is no hours rule or mandatory time off between shifts etc. The more you soften residency the more rude of an awakening you are going to have once you finish training. I was initially all about the hours rules but during my 2nd year of training (when your not just doing scut work) and I saw that the attending I was up with on call all night still had a full day of cases or operating to do that next day while I was going home. I admit the attendings are generally not on call as frequently as you but still you need to have that stamina in the real world. If you argue the hours should apply to attendings then you need 10-15 yrs to train enough extra physicians to take up the slack or you now have socialized medicine. The single most important rule in my opinion is 1 day off in 7 on average, beyond that I think thirty hour shift is reasonable. Just my 2 cents.

skialta

 

[MeowMix]

I completely agree with skialta. My analogous experience is following a patient through a long and complex labor, then having to leave the hospital prior to the delivery. There is a lot to learn from these cases, and personally I would rather be able to follow start to finish. I also agree that if you don't learn how to cope with your fatigue as a resident, you will have to learn as an attending, when the stakes are considerably higher and there is much less of a safety net.

 

[Law2Doc]

I completely agree with skialta. My analogous experience is following a patient through a long and complex labor, then having to leave the hospital prior to the delivery. There is a lot to learn from these cases, and personally I would rather be able to follow start to finish. I also agree that if you don't learn how to cope with your fatigue as a resident, you will have to learn as an attending, when the stakes are considerably higher and there is much less of a safety net.

Truth.

 

[RDlv]

And as Quik said, I agree. Go PA for primary care. Mid-levels are scary to me so I would never specialize in family practice or primary care. Mid-levels will take over PC with 20 years.

I can offer a counter to this (though perhaps not the most wise), as well as address the original post.

I am mid-way through FNP training. I've learned a couple of things in my clinical experiences so far. One is that I really love family med more than I thought I would (coming from an ICU nursing background). And the second is that I NEED to go to medical school if I really want to practice family medicine.

Residency training is a huge part of why I think this. I realize that PA was specifically mentioned above (like anyone on SDN would recommend NP, lol), and that they get much more clinical training than us. But speaking only for myself, working with physicians in a family practice setting has made it instantly clear to me the level I want to be operating at. Not in terms of pay or authority (which I have no illusions about), but in terms of knowing my own limitations and being able to treat patients without a constant awareness of the immense ocean of ignorance that surrounds my diagnoses. Ignorance that no amount of "going home and studying up on my patients after work" is going to alleviate.

Consider the FNP as the reductio ad absurdum of the discussion happening in this thread...if three years of 80hr/wk (or more) residency is overkill for primary care/family med, just keep whittling it down, down, down...until you get down to ~700 hours of clinical (whopping 15/hr per week!) and all on-line lectures. One semester of pharmacology, one semester of patho...heck, you all know the stats by now.

 

[ShyRem]

You, RDIv, are someone I would hire in a heartbeat as a midlevel in my clinic. And I would teach you. Alas, however, I'm not family practice, I'm IM and at this point I want to do hospitalist medicine.

You give me hope about midlevels. A voice of reason, humility, and hunger to learn. Thank you. Please keep posting.

 

[jl lin]

I can offer a counter to this (though perhaps not the most wise), as well as address the original post.

I am mid-way through FNP training. I've learned a couple of things in my clinical experiences so far. One is that I really love family med more than I thought I would (coming from an ICU nursing background). And the second is that I NEED to go to medical school if I really want to practice family medicine.

Residency training is a huge part of why I think this. I realize that PA was specifically mentioned above (like anyone on SDN would recommend NP, lol), and that they get much more clinical training than us. But speaking only for myself, working with physicians in a family practice setting has made it instantly clear to me the level I want to be operating at. Not in terms of pay or authority (which I have no illusions about), but in terms of knowing my own limitations and being able to treat patients without a constant awareness of the immense ocean of ignorance that surrounds my diagnoses. Ignorance that no amount of "going home and studying up on my patients after work" is going to alleviate.

Consider the FNP as the reductio ad absurdum of the discussion happening in this thread...if three years of 80hr/wk (or more) residency is overkill for primary care/family med, just keep whittling it down, down, down...until you get down to ~700 hours of clinical (whopping 15/hr per week!) and all on-line lectures. One semester of pharmacology, one semester of patho...heck, you all know the stats by now.

As a critical care/ICU nurse, I applaud what you have stated. Remember that what we have learned from working is such settings will only get stronger with the right education and mentoring and so forth.

 

[RDlv]

You, RDIv, are someone I would hire in a heartbeat as a midlevel in my clinic. And I would teach you. Alas, however, I'm not family practice, I'm IM and at this point I want to do hospitalist medicine.

You give me hope about midlevels. A voice of reason, humility, and hunger to learn. Thank you. Please keep posting.

This is always the model I envisioned when entering FNP training. A dependent position, akin to a "medical apprenticeship," where I would use the very minimal clinical base received as a nurse and as a NP student, and build upon it with the kind assistance of physicians who were motivated to teach. Having been exposed to physicians, I've come to see that the "teaching gene" is strong with you all (I'm sure there are exceptions, but I haven't run into any). I'm assuming this is a reflection of experiences in med school and residency, that nurse-dreaded "hierarchy" we all hear about (i.e. where the seniors are expected to teach the juniors of their profession, and the juniors are expected to reciprocate with some respect and willingness to do some grunt work in the meantime); the very best amongst my profession share this thinking.

And such NPs and student NPs as me *do* exist. Alas, I've also been closely tied into both the political and academic sides recently, and have been disappointed what I've learned. In a nutshell, I used to believe that a lot of what got written on here and by our allnurses provocateurs was exaggeration and good ole' internet hatin'. I have since learned that the stuff that gets written isn't too far from the truth, especially as regards the DNP and what it's proponents plan. I've been close enough to observe the growing pains of a newly developing DNP program, as well as a state-wide effort to both eliminate the collaborative agreement requirements as well as some tricky back-door efforts to disenfranchise masters-prepared NPs in favor of DNPs. I'm sure nobody wants me to turn this thread into "FNP Undercover", so I'll leave it at that.

To get back to the original topic of the thread...I think residency sounds like an exciting, daunting opportunity. My FM preceptor passes along to me things he learned in his residency, e.g wound care from surgeons, belly care from GI docs, etc. The internist in the office (who I haven't worked with as a student yet, but who has already demanded I return to do my adult rotations with her) tells similar residency tales. I support you all in defending this aspect of your profession's education. Along with the foundation in science and selectivity in admission, residency is one of those things that make doctors (and you know exactly what I mean by the word "doctors") the unique professionals that they are.