What happened to internal medicine training?

Dr. Wes has this provocative post – Medical Residency’s Decline.

The Wall Street Journal’s Health blog has a review of an article published in the Archives of Internal Medicine regarding the perspective us “old-timers” have on residency training. The comments that ensued on that blog demonstrate the fervor that residents feel regarding the cheap labor and long hours they provide for hospitals, and certainly, no one wants care provided by an individual who can barely stay awake.

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I see many, many more patients shunted to in-hospital hospitalist services that are productivity-driven. These eager inpatient attendants to health care are a formidable challenge to managing inpatient teaching services: patients are seen quickly, decisions expedited, and lengths of stay minimized, making a powerful inducement for hospital systems to employ these services. Teaching services are rarely as efficient since teaching takes time and, regrettably, time is money. After all, exceeding lengths of stay and the razor-thin cost margins that hospitals must work within to make ends meet are quickly upended. Where is the financial incentive for the teacher to teach? Training hospitals get a reimbursement bonus for training from our government, why not our teachers?

Dr. Wes has a variety of complaints. retired doc has other complaints – Still more on house staff duty restrictions-faculty angst

While no evidence of patient safety problems were presented the faculty reported worsening communication with patients and diminution in overall quality of care ( I am not sure how quality was defined). While there was said to be lower levels of resident fatigue and improved personal-professional life balance the faculty believed generally that resident education suffered as did the accountability of the residents to their patients along with decrease in the resident-patient relationship and according to some faculty there was worsening professionalism among the residents. As faculty did more work while house staff did less work, faculty satisfaction decreased. There seemed to be less time for teaching and learning.

This is not a hard data article but a presentation of the impressions of IM resident training program teachers most of whom trained in a era that was very different. One difference is that many faculty likely grew up medically with their limbic cortices branded with the concept that as a professional obligation they should place the needs of the patient above their needs and the primacy of that directive seems no longer to hold the same exhaled position in the medical ethical scheme.

Every generation seems to criticize the generation which follows. Back in the good old days ….

I was chief medical resident in 1980, joining the faculty the next year. I have taught residents and medical students for 27 years. At the institutions where I work this generation is great.

Dr. Wes is correct that some hospitals would rather have private hospitalists care for patients. Program directors and chairs of medicine must fight that trend.

At our institution we established the hospitalist program to decompress the general internal medicine service (which had fallen off the Starling curve.) We designed our program so that unassigned patients are randomly distributed between the teaching service and the private hospitalist service. Our program director and chair are proactive in making certain that the housestaff have the appropriate number of patients for their education.

Our program director also has worked with the housestaff to develop systems of call and night float which maintain the fundamental educational principles as well as professionalism.

I know that it can be done right, because I see it being done right. The key here is that programs must titrate the clinical load to optimize education. Education includes caring for patients, learning at the bedside. We cannot learn medicine at the board, but rather we must have real patients to consider.

The students and residents that I encounter have the “right stuff.” Perhaps our institution has reacted to changes in a positive proactive manner, while others have not.

I do enjoy having interns and residents who are eager to learn, because they are not as angry as previous generation. Remember that sleep deprivation causes free floating anger.

What I have observed is that evaluating new patients rarely causes anger. Cross cover responsibilities were the killer of personalities and compassion.

Should that be so? One could argue that it shows our immaturity to get mad for inappropriate pages or calls. I would counter that admissions are expected when one is on call. You are prepared for admissions. Cross cover calls disrupt ones control.

Classic examples include – the patient cannot sleep (2 a.m.), the patient is constipated (3 a.m.), the patient has not made any urine in the last 20 hours (4 a.m.). All of these calls could be anticipated – thus the anger.

Night float interns (at our institution) have this as their job for one month. Everyone understands the trade-off.

We should not blame ACGME or hospital administrators for changes in internal medicine training. Rather we remember the slogan my wife had hanging over the urinal – “When God gives you lemons, make lemonade.”