I've been off in a wilderness called "medicine" for the past two months; all psychiatrists are expected to do four months of general medicine training in our first year. Mine is split as one month of adult inpatient, two months of pediatric inpatient, and one of adult emergency (which everyone loves, because it involves neither call nor morning rounds).
As you might surmise from the months of sudden silence, it's been busy. It's not just the call, though. It's taken me a while to adjust emotionally to a very different environment and a different way of taking care of patients. There is, obviously a lot less talking to your patients, and a lot more talking about them -- presenting them to the attending on rounds, telling consultants about them, talking to their nurses, calling radiology about their x-rays and CT scans, calling social work to arrange discharges, and so on. For someone who went into psych specifically because it's the specialty where you get to spend an hour minimum with every new patient, that's less than desirable.
The bigger issue, and the one that constantly frustrates me, is that medicine wards everywhere are basically set up such that my survival depends on taking bad care of patients. The issue is simple: a medicine intern's patient load is not fixed, as it is on psychiatry. In psych, we have a bed shortage, nationwide. As such, the inpatient units are always full. The workload has been calibrated such that taking care of a full unit will be difficult, but still doable while keeping work/life balance (and attending to all the non-patient-care items that constitute "work", such as conferences, research, reading, teaching, etc.) No so the medical floors. Every intern has a variable census. At Harborview, our adult hospital, you can be responsible for up to ten patients. Roughly speaking, you're required to pick up five more every fifth day when you're on call, plus two more in the middle of the call cycle -- seven additions every five days. You keep caring for them until they leave. The problem is simple -- nobody can take competent care of ten adult medicine patients. The paperwork and diagnostic/treatment load required is beyond a junior doctor's faculties. The actual "happy medium" for learning varies, but mine is somewhere between five and seven. At Seattle Children's, where I am now, it's similar but without the cap -- each call night could be anywhere from three to ten patients, and I've had my service hit thirteen[1]. (Thankfully, at that point the senior residents took mercy and did some redistribution before I died.)
In such a system, all your efforts have to focus on one thing: get the patient out the door as fast as you possibly can. When you're on call, the principle is similar: do the minimum necessary work on each new patient, because a flurry of admissions or a serious crisis on existing patients could happen at any minute. It's a constant race to get ahead of the tide. Personally, I feel that this leads to suboptimal care; maybe not actually "bad", but definitely not the care I'd want my own family to get. How can your doctor truly care for you when all his/her incentives are about minimizing contact, minimizing time, and getting you just stable enough to be hustled out the door? It does function -- most patients don't get readmitted, at least not immediately. It just doesn't provide the quality I'd want from the world's most expensive health care.
Of course, it's not all bad. I'm not going to say it's educational; the actual amount of learning about medicine is minimal. Mostly I learn how to do paperwork and what this particular hospital's protocols are. At best, it's an exposure to ward workflow so I can be more helpful in second year, when my primary role will be consulting psychiatrist for those medically ill patients who also have mental health needs. What it does do is really make you appreciate your free time. I find myself being more efficient in my days/hours off, because I know the clock is about to start again. I also think I will never again complain about psychiatry's less-than-once-per-week call schedule.
The other nice thing is occasionally getting one of those medical patients with psych issues, because for once, I can take care of someone from both angles. The average medical resident tends to be profoundly uncomfortable with someone who's suicidal, or majorly drug-addicted, or psychotic. I'm no expert on any of those, but at this point I've seen them enough to not panic. What I don't yet have is enough experience in the management of the many kinds of toxic overdose, or the infections that result from IV drug use, or the complications of rampant diabetes. Having someone teach me about those while I get to also treat the psychiatric problems is profoundly satisfying, and almost fun. I've daydreamed about trying to find a way to make more of our "medicine" time focus around that scenario, but haven't quite come up with it. It'd require having a kind of dual-attending med-psych service and the underlying administrative structure; a great project for a chief resident to undertake, but not really doable by an intern (at least, not one on medicine months).
In the long run, mostly the past two months have confirmed to me that I picked the right specialty. Some of the patients were interesting, the pediatric ones are cute, and a few have even been grateful. Still, if you told me I was going to spend the rest of my life managing electrolytes and infections, I'd quit and go back to the lab for good. There's only three (ish) more weeks and six more call nights before I get to put off the white coat, mothball the stethoscope, and get back to shrinking heads. It's good to be in the home stretch.
[1] The astute will note a potential upside -- if you are REALLY lucky and get just the right kind of simple admissions a given call night, it is possible to actually discharge everybody before your next call. This has happened to me twice in my three months; it's a magical feeling.
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So, um, since everybody wants to be a doctor, then why aren't there enough doctors to handle the workload without hospitals always being in crisis mode, as you describe?
ReplyDeleteIt's complicated. I think that might be a good post topic, and will work on writing one. Briefly, "artificially created shortage" is the short answer. There's also a sort of pyramidal thing -- if all the doctors at all training levels spread the load evenly, then nobody would work as hard, BUT, you also wouldn't get to know that with every passing year, your overnight/weekend burden would lessen. It self-perpetuates because interns are too busy surviving to change the system, whereas once you're not an intern, you forget how much it sucked and thus have no incentive to alter it.
ReplyDeleteKind of analogous to why professors tolerate there being such bad work conditions for grad students, even though they were all grad students themselves and were mad about those same conditions at the time.
(nods nods) I second the "it's complicated" note.
ReplyDeleteAs Alik noted, while resident work hour reform has dramatically reduced intern work hours, it instead simply pushed that work upwards. Senior residents, fellows, and attendings now all work far longer, to make up work that their juniors no longer do. Your intern may only work 80 hrs a week now instead of 120-140; but now your full *attending* works late nights and weekends to make up the difference.
Some of that work has also been taken up by nurse practitioners, whose role has massively expanded as resident work hours fell. An undeniable good for the sub-specialist physician who now can call on an army of nurse practitioners to help her manage her patients. But for the generalist physician -- who still make up a substantial fraction of all physicians and all new physicians: the question of what exactly their role is, vs. a nurse practitioner who invested far fewer years and dollars in student debt, is an unsettled -- and unsettling -- one.
Additionally, there is the fact that the federal goverment -- and ultimately, the taxpayer -- makes a substantial contribution to the training of all physicians. Even the most expensive medical school tuition only covers a portion of the true cost of educating the physician, the rest ultimately covered by the public, through taxes and indirect assessments. And taxpayers are *completely* resopnsible for footing the cost of training all residents, whose training can be double or even triple the length of medical school, as well as actually getting *paid*. And that doesn't even include the inevitable human cost of being cared for by trainees -- every patient who became a pincushion as a medical student learned phlebotomy; every surgical patient with a jagged scar from a trainee surgeon; every academic medical center patient who has had to endure being examined every morning by the student, the intern, the resident, the fellow, *and* the attending.
In contrast to most other professions, the cost of training a physician is not borne primarily by the would-be professional, but instead is actually borne *primarily* by the public at large, a price paid in dollars and literal suffering. As substantial the price paid by physicians to become physicians -- and it *is* substantial -- the price borne by the *public* is even higher, in dollars and literal suffering. Training too many physicians means wasting taxpayer dollars and patient sacrifice, an unacceptable mis-management of both resources: hence the extremely tight control of physician supply.
And there are still more angles than those. As Alik noted, it is a very complex issue.
And that leaves out one of (in my opinion) *the* most important drivers of work hours: health insurance, or the lack therof.
ReplyDeleteA dentist, for example, is allowed to turn away patients who cannot pay sufficently well, no matter how desperately that patient needs dental care. A dentist can *choose* to serve the poor to the degree they see fit, but has no obligation to serve. A physician, however, does (and in my opinion, should) provide basic, life-saving medical care to those who come to her, regardless of ultimate ability to pay.
We have decided as a profession (appropriately, again in my own opinion) that the average working American should not be turned away from an Emergency Room to die merely because they cannot clear the credit check. Unfortunately -- in contrast to most other industrialized nations -- we don't yet have a systematic way to actually *pay* for that health care, instead relying on a whole series of rob-Peter-to-pay-Paul shenanigans whose complexity is *way* beyond any mere comment. One of which is the fact that a resident -- or his public or academic medical center attending -- gets paid exactly the same whether he works 40 hrs a week -- or 80.
The need is substantial. At my academic medical center (one of the NIH top 5), literally 50% of my pediatric patients are on public aid. In most other professions, those customers -- the 50% of children on public medical aid -- would simply do without, secondary to their inability to pay market rates. We in medicine (appropriately, again IMO) insist that the members of our profession provide our services *regardless* of the inability to be paid at customary rates.
After a certain point, seeing more patients doesn't earn you more money. In fact, seeing more patients *costs* you money and profit. Patients with "bad" insurance -- or *no* insurance -- are money *losers*. But they are still patients in need, patients who are suffering, patients who are dying. The American public expects physicians to serve them first and their pocketbooks second (an opinion I happen to agree with). And so, in the absence of a systematic way to pay for it all, we make do.
Instead of hiring more people to care for them with the money that isn't available, we just make everyone work longer, effectively making charity care a required part of the careers of trainees and those who serve in our nation's safety net hospitals (which also include it's major, cutting edge academic medical centers.) In the end one way to think about it is to say that the first 40 hrs a week we work is for customers who pay well. And the *next* 40 hrs a week are for the customers who can't.