Training then, training now
Medical Rants April 26th. 2008, 8:14pm
Yesterday, while visiting UCSF a colleague asked me to compare training then and training now. This question came as part of a one hour interview for interns and residents. As I answered the question, I simultaneously thought that this question would make an interesting blog topic.
To set the context, I finished my internal medicine training 30 years ago. I have taught residents continuously since 1980. Most physicians from my cohort will tell you that our training was more difficult.
Training then
I worked every 3rd night as an intern, then averaged every 4th as a resident. The only days I ever got off were Sundays after Friday night call. We had no caps, and occasionally did admit more than 5 patients in a 24 hour period. We were explicitly expected to stay at least until 5 p.m. on our post call day. We averaged over 100 hours each week.
Training now
My interns work every 4th night, but only stay over night on Fridays, Saturdays, and half of the remaining days. They have a cap of 5 admissions. They must leave work at 1 p.m. on their post call day. They get at least 4 days off each month. They have a 80 hour work week cap.
Training then
We had little pressure to discharge patients. We had no utilization review nurses. Length of stay probably averaged a week.
We had many less diagnostic tests and fewer treatments. We had no CT, no MRI and limited ultrasound (really only M-mode echo.) We never had to use vancomycin (no MRSA.) We had no HIV.
We treated MI patients with lidocaine, morphine and nitrates, but talked a lot about how great it would be if we could decrease infarct size. Our major hospital did 3 cardiac caths each day. We had no interventional cardiology.
CHF patients had an average life expectancy of 6 months after their admission. We used digoxin and furosemide. ACE inhibitors became available in 1988. Beta blockers became available during my senior residency year, but they were absolutely contraindicated in CHF.
COPD patients usually developed cor pulmonale, because we had no home oxygen.
We treated hypertension with alpha methyldopa and a thiazide.
We had no histamine 2 blockers, no PPIs, and no 3rd generation cephalosporins.
Training now
Obviously, our residents have the things that we did not have, and much more. Current residents have much greater supervision (and thus too often micromanagement.) Current residents experience a much shorter length of stay, and have great pressure to discharge patients quickly.
We can do much more for each patient, and we make much more accurate diagnoses.
Which is better, more difficult, more appropriate
This comparison is impossible, because the context of the comparison has changed so greatly. In the 70s, our senior attendings puffed out their chests and bragged about how much harder their training was. Now most of my cohort would say the same thing about current trainees.
The older generation always view their history as being more relevant and more stringent.
I believe that internal medicine training has always required hard work, both intellectually and much time. To try to compare then and now is really not possible.
I personally believe that training is more difficult than ever. Our residents are dedicated to learning our difficult specialty. They struggle with the current social context of patient care.
Our field has changed. We have more responsibility because we can do more. Our subspecialists have deeper knowledge of their subspecialty field, but generally narrower knowledge of the breadth of internal medicine.
I hope that those of my generation will chime in. I hope that current and recent trainees will comment also.
April 27th, 2008 at 10:02 am
In our hospital the residents go home after morning rounds the day after call. I used to think it was pretty lame that they didn’t feel capable of doing my morning rheum clinic, but I’ve since changed my mind. When they do show, they are well rested and seem interested in the cases we share. That was not the case in the old days post-call. When they don’t show because they are post-call, I don’t teach and the clinic moves along quickly. Win-win.
I do wonder how doing 20% less hours affects the end product. I get the feeling that the 3rd year residents I see are not as good as R3s in the past, but I don’t think it’s the case after subspecialty. They may be less well-rounded internists, maybe they have to consult more, but I’m not sure that it’s that important. In any case, a few years out of residency and we generally lose most of our confidence in off-specialty skills.
What I wonder about most is the decreased call. I don’t question the benefits of limiting the number of hours worked,( I once remember getting the nods while taking the history of a cardiac patient) but as your last quote in the sidebar says, education is being able to differentiate between what you know and what you don’t. There’s nothing quite like night and weekend call to help you realize what you don’t know.
Note: I did internal med and rheumatology during the eighties
April 27th, 2008 at 10:21 am
Oh boy! The Way It Was stories!
My experience was just a little later than DB’s, as I graduated in 1983. CT was common, MRI was just beginning (it was called NMR, nuclear magnetic resonance imaging, until someone decided the ‘nuclear’ was too scary). HIV was just beginning to be an issue, and MRSA was also rare.
As a third year medical student on internal medicine, call was every third, but volume was the problem. Our service (one resident, one intern, two students) covered 35 beds, and on call covered 105 (including the other 2 services in call rotation with us). Of the 105, generally 6 to 10 were in, going in, or coming out, of the ICU, and the resident spent 95% of his/her time on them (to preserve continuity, once a patient was on your service, you followed them wherever they went in the hospital–except the morgue). This left the intern to admit about 18 patients a night. Very bad system for learning, since all you wanted to do the next day during ‘teaching rounds’ was to take care of the patients who came in the night before and tune them up enough so you didn’t feel bad about dumping active problems on the next night’s call. Everyone took every opportunity to bag out of rounds to cover patient problems, and never return. Those on call that day were usually already admitting patients, so about the only ‘academic’ learning occurred on the day between calls. And then you were punch drunk after being up 38 hours straight and crashing for 10 hours.
On the other hand, the ‘non-academic’ learning (aka, non-verbal or procedural learning, feel, art of medicine, etc.) was excellent. It takes multiple exposures to diseases/signs to develop any expertise (one can argue about the number, I believe it is 20 for basic understanding, 50 for beginning expertise, and 100 for true expertise), and lower numbers means residents are leaving with more ‘book’ knowledge, but less clinical expertise.
Finally, one amusing anecdote. As an intern I was on a 60-bed geriatric service. As one of the early efforts to improve teaching, we had four interns (call 1 in 4!) but because length of stay was dropping radically, we still averaged 15 admissions per day. (One intern had 26 admissions on her call day because we had discharged half the service–fortunately 5 came in early so the rest of us pitched in and admitted them since we knew she was going to be killed that night.) Among the transitions occurring was an increasing number of women physicians, and the other three interns with me were all women. The first three days of the service I was called about a dozen times to put in urinary catheters into male patients. In each case the nurses said it was a difficult insertion and that they had called Intern X1, X2, or X3 and she was not available. At lunch the third day I mentioned to one of the other interns that the nurses seemed to have a lot of difficulty with relatively easy catheterizations. She said that she hadn’t been called to do any at all, and then when realization dawned she went to the other two interns and they conferred. They then told me “we will handle this” and stomped into the head nurse’s office. It turned out that the head nurse believed it was unseemly for a woman to catheterize a male patient, and so all male patients were done by doctors. This had been going on for years, but previous intern teams had had at most one woman physician, so the nursing staff got away with it by rotating her patients among the other three interns. The converse was not true, in that if the catheterization was truly difficult, a male physician would catheterize a female patient. This was one of many hidden issues on the relative status of male and female doctors that had to be resolved as more women entered medicine, but in my experience, one of the more amusing.
April 27th, 2008 at 4:30 pm
If the comparison is impossible, then why make it? As a medical student we are forever hearing this “it was so much harder for us/you have it so easy” chorus, despite the fact that the sheer volume of medical and scientific knowledge grows exponentially every year. What’s wrong with trying to make things better for succeeding generations of students and residents? The argument that longer hours are better for training physicians always strikes me as specious; they almost always come along with some story about falling asleep in the middle of taking a history. How is that good for patient care? What if the resident fell asleep in the middle of a procedure, or at the moment the patient said she was allergic to penicillin? How about improving training instead? We don’t want truckers or airline pilots working 100 hours a week because if they fall asleep people get killed. Expecting physicians not to make mistakes under the same conditions is insane.
April 27th, 2008 at 9:49 pm
to mha-
however, the primary goal of training is to develop the required skillset you need to practice safely and effectively. the questions are whether that is occurring. imo, it is not. i see plenty of people coming out of training every year. typically it takes a few years to really learn to practice effectively and efficiently. everyone understands that when someone new enters the community there will be some silly consults. what we don’t expect is dangerous care, which is increasingly what we are seeing in my community. it is unclear if that is because of lack of knowledge, lack of commitment (used to 80 hours/admission caps), or just the individual in question. but in distinction to the past, we see the new practioners not getting better, but rapidly focusing on business aspects of medicine. this might be due to the loans or increased pressures on practices to get them up to speed, but it is something we see regularly.
there is no question that falling asleep while taking care of patients is not a good thing.
please understand, i believe most of the commentary here is directed to finding the best way to achieve the goal of preparing trainees for practice, not blaming them for wanting to sleep. personally i place a good chunk of the blame the program directors and academics for allowing the abuse of housestaff (we were social workers, we were phlebotomists, housekeepers) to occur that necessitated a reduction to 80 hour workweek. the thing is, once you graduate, it doesn’t matter whose fault it was. it is all your own problem. i honestly don’t know what the best solution is. it may well be to add another year of training, unattractive as that may be.
April 27th, 2008 at 11:02 pm
To MHA
Nodding off during a patient assessment is nothing short of scary and that it why I used it to underline why ” I don’t question the benefits of limiting the number of hours worked”. We’re on the same side here.
The question remains though, how do residents today learn so much more stuff than I did, and try to put it all to practise, in what is effectively a shorter residency?
It’s possible that simply being less sleepy makes residents today more efficient. We’ll see.
April 28th, 2008 at 12:29 am
Nobody has given any objective evidence that today’s new graduates are any less skilled than those in the years past. All we’re given is anecdotal hogwash.
April 28th, 2008 at 4:33 am
Nice post
April 28th, 2008 at 7:10 am
trifling jester-
when you get into practice you’ll find that many patients inconveniently don’t fit into studies or guidelines. or that you don’t have time to read all the guidelines. or that the guidelines themselves are based on anecdotal hogwash. and then you’ll have decisions to make based largely on anecdotal hogwash.
April 29th, 2008 at 3:26 pm
I think DB may be misremembering about ace inhibitors. Captopril was introduced in the late 70s, albeit mostly for htn. Otherwise his view of what we did at that time seems pretty accurate. I still remember my introduction to the treatment of MI–”there’s nothing we can do about it, but we can treat the complications.” I also remember the highly academic program director at our school’s associated internal medicine residency laugh at an ER doc for getting a head CT (then a high tech novelty) on a patient in the emergency room. That was an inappropriate use of high tech when clinical skill hadn’t been given a chance to solve the problem…
By the late 80s when I completed residency training had been transformed by innovations in imaging, interventional cardiology, and pharmacology. Interestingly, we still used CT scanning a bit more conservatively than we do now. We never, for instance, routinely CT’d abdominal pain patients in the emergency room, as is now standard at my university hospital.
I think the changes in work hours are absolutely warranted; I quarrel only if the rules are so rigidly applied that patient care suffers, which I think is a danger. My morale as a resident (and, I’m sure, my learning) would have been vastly improved by a day off once a week or so; rather than once every 6-8 weeks as seemed to be the general rule.
My sense is that at least in our university program, changes in training over the years have not lessened the level of competence achieved by our good residents. They are every bit as good as we were back in the day, that is, comparing residents of similar smarts/aptitude. I suspect that the salutary changes in work hours have improved the degree of academic (vs practical learning) that most residents achieve; and I do not see a lessening of practical competence.
The present challenges to training include preserving and developing a generalist outlook that values undifferentiated problems in an era of ever-increasing specialism; preserving professional commitment in the context of work hour limitations; and protecting the educational mission in the face of increasing demands of various sorts imposed upon hospitals by the payment climate.