Medical education has always been about exposure to the most permutations of illness across the broadest spectrum of disease. That can only be accomplished with repetition. If you want to become an expert in the management of common and uncommon presentations of common and uncommon disease, you have to go to where the pathology is. And guess what. That's not in a stable outpatient clinic setting. A hospital is where you need to be. You aren't going to see that raging case of tortuous aorta or bilateral hydronephrosis at a nurse practitioner run urgent care clinic on a sunny Tuesday afternoon between 1pm-4pm. You're gonna see it when that stoic country farmer, who refused to listen to his wife for three weeks, shows up in the ER at 2 am when the pain becomes unbearable. If you're an intern on July 1st, 2011, you might as well hang out at the urgent care clinic between 1 pm and 4 pm, because you'll get the same experience now that the Accreditation Council for Graduate Medical Education (ACGME) has slaughtered the intern's educational experience.
One of my new partners fresh out of residency has described exactly what the new intern work hour restrictions for 2011 has meant in the real world delivery of hospital based health care. For the last few years, residents could work no more than 80 years per week, averaged over 4 weeks. How about now? Here are the new intern work hour restrictions for 2011. I have high lighted a few of the new rules below.
- Interns can no longer take home call. Ever. Why is that? Because the new rules mandate that PGY-1 (the fancy abbreviation for interns (also known as first year residents) ) must have direct supervision (supervisor physically present with the intern and patient) or indirect supervision immediately available (physically present somewhere in the building). Interns are considered too stupid from answering anything medically related without a supervisor immediately available.
- Interns may not exceed more than 16 hours during a continuous work period.
- Interns should have 10 hours of freedom from work duties but must have at least eight hours of free time between scheduled duty periods.
- Interns must get at least 24 hours off for every 7 day period, averaged over 4 weeks.
- Interns are not allowed to moonlight
That is a brief summary of our new intern work hour residency restrictions for 2011. So how did the University Mecca that I trained out decide to solve the man power issues to comply with these new work hour restrictions?
- Interns no longer pre-round before morning report. If they did, they couldn't...
- Stay in the hospital until they completed their 10 pm shift to take all cross cover pages and admissions. They would have to go home sooner and that would mess everything up.
- Once 10 pm hits, interns must go home and entertain themselves. All internal medicine admissions are now handled by moonlighting fellows looking for extra cash because all the academic hospitalist attendings have no night call built into their contracts. That's awesome.
- The fellows must now take first call after 10 pm if they have an intern on their service. If I was a fellow, I would do everything in my power to avoid interns. They are now worthless, which is pretty equivalent to the status of a medical student on rounds.
May God help us all. If we train under experienced interns and release them into a supervisory role, we end up with under trained supervisors training under experienced interns. These supervisors will become under experienced attendings and the race to the bottom will be codified in the name of patient safety. Interns have just become really expensive medical students (paid for by the Medicare National Bank) while we pawn off patient care duties to the moonlighting allergy and immunology fellow who could care less how thorough a work up they did, as long as they can pawn off the patient to the intern in the morning who got five hours of sleep after closing the bar down on karaoke night. Congratulations interns. You've hit the jackpot. Where else can you earn $50,000 a year as a highly paid medical student with more time for drinkin' and less time for thinkin'?
Are surgical residency programs complying with the 80 hour work week restrictions and other rules deployed to protect interns from not working harder than a single mother with three jobs trying to make ends meet for her three children or is it all just a big lie? God forbid we have surgeons trained to experience vast permutations of unGodly imaginable pathology with infinite permutations of complications. The answer to the question lies in in the data that is collected. I asked that question of a father who's son is currently an intern in an East Coast surgical residency. The father laughed. Here's how he said his son explains it:
Chief Resident: Intern, how many hours have you worked this week? (wink, wink)
Intern: I have worked 76 hours on paper, sir. (wink, wink)
Chief Resident: Good job intern for staying below your limits. (wink, wink)
Intern: Of course. (wink, wink)
As far as the residency programs are concerned, if you didn't document it, it didn't happen. Now, where have I heard that before? Sounds to me like surgical residencies have an unwritten rule that you will work more than 80 hours a week or you will not be asked to move on in the program. If you're an intern, I can assure you there is no way you are going to be the fall guy for your program. If you take down your program as a whistle blower, you will be left without a job and nobody is going to hire you because, as far as you know, everyone is complacent in their participation of bending the documentation to comply with the rules. These obnoxious unfunded mandates turn honest and hard working people into dishonest liars. Next up, the 56 hour work week. Nothing to worry about though. These doctors are going to get plenty of training. Just remember if you didn't document it, it didn't happen.
Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.