A day late and a dollar short.

Trying to measure up.

"Here comes the sun
Here comes the sun
And I say. . . 
It's alright."


~ George Harrison of The Beatles
_____________________________________________

 
On December 2, 2008, The Institute of Medicine released their greatly anticipated report on “Resident Duty Hours.” Like many academic physicians, I sat in front of my computer listening to the live webcast, trying to make sense of their recommendations for more sleep and less continuous duty hours for resident physicians. I perused the New York Times article that followed, but it wasn’t until I read the subsequent barrage of online commentary that it really set in.  Let me tell you--folks were not happy.

“We are officially in the ‘No Accountability Era,’” one physician wrote. “Our patients will be the ones who suffer from the ‘clock in-clock out’ monsters that we are creating.” I read on, serving as my own amen choir with exaggerated head nods. Another passionately added, “Our residents are becoming more interested in getting out of the hospital than getting to know their patients.  No one seems to care anymore. This will only make it worse.” 

Ouch.

Next came recommendations from the Accreditation Council for Graduate Medical Education (ACGME.)  These recommendations first came as ones that weren’t etched in stone. They said, “Okay, interns—meaning first year resident physicians—need to get up out of the hospital after sixteen consecutive hours of work. Oh, and you faculty? Y’all need to do a little, no a lot, more supervising. For real.”   Okay, maybe this isn’t exactly how they said it, but that was my take on it.

After that, the ACGME solicited input from a bunch of academic institutions and professional societies.  We had a slew of institutional meetings at Emory to discuss our suggestions and with the help of leaders in our Graduate Medical Education Committee, sent them off. Organizations like the American College of Surgeons sent theirs in, too, and man. . .  they didn’t sugar coat things. Like I said. . .folks were concerned. No, more than concerned. Folks were worried. And folks meant us.

The thing is this: If an intern can’t work beyond sixteen hours straight, it means that they can’t work overnight. A lot of folks will tell you that their biggest learning during training went down in the middle of the night.  I wish I could say that I didn’t agree with that. But for me, it’s true.

Well, turns out that the ACGME came back with the official recommendations after getting all of that feedback, which essentially was:

“Okay, interns—meaning first year resident physicians—need to get up out of the hospital after sixteen consecutive hours of work. Oh, and you faculty? Y’all need to do a little, no a lot, more supervising. For real.”  

Um yeah.

Faculty weren’t so giddy about this. In fact, the “new duty hours situation” was smattered throughout our conversations in the resident continuity clinic that day. Between patients we pondered what these changes would mean to us as faculty. We worried about two years from now when more inexperienced second year residents were being expected to teach one when they hadn’t yet seen one or done one. What would that mean to us?

When the residents were out of the room, the discussion got pretty unfiltered—everyone was sharing their unsolicited stories of residency in the “real” trenches, and collectively tsk-tsk-tsking this mandate that would further pull house staff away from the hospital. Next thing we knew, the conversations kept going even with house staff around. Before we knew it, we had all exploded into a fraternity of “old school” doctors unabashedly hazing our young learners by insulting their potentially soon-to-be inferior training experience.

The irony is that there’s really nothing new under the sun. No matter when a person starts their training, there is bound to be some omission in the “new way” that appalls the village elders. We’ve all been there and felt the sting of criticism for things out of our control.  The “new way” always seems to lack the pieces necessary to build intestinal fortitude and sear the heart with nostalgia.  And it has been this way for years. The freshman experience never ceases to be a day late and a dollar short.

I can still recall this snapshot from my own internship in 1996—amid the late lunchtime crowd, I wolfed down a sandwich in the cafeteria with my senior resident following my first night on call. I couldn’t tell if the nausea that churned in my gut was a factor of the inexplicable exhaustion I felt or the pre-packaged hoagie that my two-dollar meal ticket afforded me. My upper level resident described our evening as “not so bad” when a classmate asked in passing. Not so bad? I silently protested. She must have read my mind. She turned toward me, rolled her eyes and trivialized the mere nine patients I had just admitted with the dreaded “when I was an intern” preamble.  (Major emphasis on ‘I’.)

Her, perhaps tall, tales of working up eighteen patients alone with virtually no supervision or chance of sleep in sight were further encouraged by my incredulous gasps. How could I possibly become as fearless, decisive, and knowledgeable as she with a measly one night in four call schedule and someone enforcing a patient cap? I can still feel the way my shoulders slumped down that day; ashamed for believing that it was impossible to do more than I had just done the evening before.

I grew up, and despite the patient cap and less frequent call schedule, I turned out all right. My medical knowledge increased, I accrued my own arsenal of lessons, and eventually became a clinician-educator. Time marched on, and at some point, I forgot those hunched intern shoulders. More rules came along, and eventually, I found myself duly initiated into the “old school” fraternity of those who “really” trained.

 In my ten years of teaching residents and medical students, I have certainly had moments of disappointment with their work products. But honestly, I have had far more hopeful moments about the physicians we are helping to mold. The more I reflect on the myriad of driven, selfless, and responsible residents I’ve worked with over the years, the more conflicted I feel about labeling them all products of the “No Accountability Era.” 

Our attitudes suggest that they don’t stand a chance, when the truth is that, more than likely, they really, really do. The rules were out of my control in the mid-1990’s, and today’s learners have little to no say about the current mandates. In fact, when researchers asked them what they thought about it, in a paper published last year in the New England Journal of Medicine, they made it real clear that they, too, took issue with all of these changes. Interesting situation, ain't it? 

Anyways. . . . just as we can recall the incredibly empathic and the egregiously irresponsible during our own residencies, the same exist today. Just because you work less than twenty-four hours doesn't mean you are automatically shady. Oh, and the converse absolutely applies, too--and to that I can personally attest.  Alas, there's really nothing new under the sun.

Let's be real. I can’t say that I am thrilled about the idea of trying to figure out how to do the same amount of patient service with less manpower. I also would be lying if I said I wasn’t extremely worried at times for specialties like general surgery and obstetrics and gynecology whose unpredictable schedules make the continuity of working a full twenty-four hours critical to learning the ropes. 

But still . . . I am inspired by so many of the learners I know. Many, if not most, do feel accountable for their patients. They do shed tears for their patients in a locked bathroom on the wards, and just like we did, and they are still plagued with the need to read all about their patients’ conditions.

So I guess what I’m saying is. . . .contrary to what the message boards (and sometimes we) are saying,  I can say firsthand that there are legions of caring, earnest, and accountable young physicians waiting in the wings. On July 1, these recent medical school graduates will come rushing on our hospital lawns looking for their chance to be initiated.  Now I guess it’s just up to us to find creative ways to welcome them into the fraternity.

*** 
Here comes the sun, man.  With nothing new under it. And I say? It's alright. It has to be.  
Now playing on my mental iPod (Geo. Harrison with a super-gnarly line up behind him!):