medical residents

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Opinion: Let's Talk About Residents' Hours – And Their 'Scut' Work Too

By Sefira Bell-Masterson, Dr. Lakshman Swamy and Dr. Christopher Worsham

A few things in medical education have changed in the past 100 years.

A century ago, for instance, resident physicians-in-training literally lived on hospital premises.

They received room and board but no other compensation. They routinely performed any task related to patient care, ranging from transporting patients to the operating room to performing their surgeries.

Clearly, things have changed. But what hasn’t changed is how medical residents are used for any task that needs to be done during a patient’s hospital stay.

Today, residents are expected to learn medicine, care for patients, and improve our health care system — often in addition to teaching and research. All this needs to be done within a limited number of nationally regulated duty hours, now the subject of an ongoing and increasingly controversial conversation in the medical community since restrictions were put in place in 2003 and 2011.

Over the past decade, there has been much debate about the benefits and drawbacks of duty hour restrictions, yet prior research into this topic has shown mixed results. Earlier this month, however, researchers published results of a first-of-its-kind randomized trial (the FIRST Trial) of 117 surgical residency programs across the country. The study’s authors concluded that there was no difference for patients or their doctors’ satisfaction whether residents worked under current duty hour restrictions or under more flexible rules. Results of a similar trial performed on medical residents (the iCOMPARETrial) are expected later this year.

Adil Yunis, a resident in internal medicine at Boston Medical Center, is working with hospital executives to improve the health care system for his patients and his fellow residents.

Adil Yunis, a resident in internal medicine at Boston Medical Center, is working with hospital executives to improve the health care system for his patients and his fellow residents. (Courtesy)

As residents ourselves, we believe the duty hours conversation has missed a major point: Though our hours are being limited, what we actually do during these hours is not.

There has been a great focus on the number of hours worked, but silence about the actual work done.

Erica, a resident in obstetrics and gynecology in Delaware, routinely runs her own lab tests in the office. Karl, a pediatrics resident in New York, often spends valuable time in the room with a child and her parents laboriously copying information from her medical record to fill out school forms.

Adil Yunis, an internal medicine resident in Boston, will spend 30 minutes on the phone trying to get a cardiology appointment for his patient who just had a heart attack.

These tasks (all real, but with two last names withheld ) are examples of what many residents call “scut.” Continue reading

Docs In Training Confide Their Feelings On Performing Abortions

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol July 9 in Austin. (Eric Gay/AP)

Abortion can be hard for the patient. But it can also cause turmoil for the doctor performing the procedure.

Janet Singer, a nurse midwife on the faculty of Brown University’s obstetrics-gynecology residency program, found herself acting as a confidant in many discussions with residents about abortion.

“Over the years, when a resident felt confused, overwhelmed or thrilled about something to do with abortion care, they often came to me to discuss it,” she says.

Tricky questions continued to arise: Where does life actually begin? How do doctors’ personal beliefs play out in their clinical care? And, what’s really best for mothers?

(KateLMills/Flickr)

(KateLMills/Flickr)

Singer thought the general public would benefit from hearing more about the complexities of the young doctors’ experiences. So she asked four residents to write about their feelings about abortion training and services, or as one resident characterized it: “one of the most life-changing interventions we can offer.”

These personal stories are published in the July issue of the Journal of Obstetrics and Gynecology, headlined: “Four Residents’ Narratives on Abortion Training: A Residency Climate of Reflection, Support, and Mutual Respect.”

I asked Singer to offer a bit more background on the project, and here, edited, is her response, followed by some excerpts from the residents’ narratives:

Janet Singer: The abortion debate in the U.S. is so divisive, making everything seem black and white; but the real life experiences of doctors and women are much more complex. I am a nurse midwife and though personally committed to increasing access to abortion services, I believe that abortion is not a black and white issue. I speak openly about my personal beliefs with the obstetric residents I work with.

My thinking about the grey areas surrounding abortion care are the result of many conversations with colleagues and residents. One came to me overwhelmed on a day when she had done a late-term abortion and then been called to an emergency C-section for a fetus/baby just a week further along.

She needed to talk about how overwhelming it felt to try to decide where the cusp of life was, why it was OK to take one fetus/baby out of the womb so it wouldn’t live and one out so it might.  Continue reading

Turf Battle: The Podiatrist Vs. The Medical Resident

Podiatrist: We are professionals too

A post earlier this week on the Massachusetts Medical Society opposing a slew of proposals that would give greater authority and clout to podiatrists, midwives and optometrists, among others, set off a thoughtful debate among CommonHealth readers.

On the one hand, some MD’s said that their extensive training set them apart from other, so-called “paraprofessionals,” and to give these lesser-degreed providers greater scope in their practices could put patients at risk. Alternatively, non MDs said their expertise should not be trivialized, and doctors are simply trying to hold back competitors and thereby protect their cushy incomes.

Here, Dr. Alec Hochstein, a New York podiatrist, notes that the team approach– including the ability to interact and consult with peers who have different but complementary areas of expertise — is what truly benefits patients:

I do not want to get into a debate over who knows more or who is better qualified to treat what condition. I am quite comfortable in my area of expertise, which encompasses specialties in multiple systems. I do not care what letters you have after your name, I only care about how you approach a patient, and their conditions, whether it be cardiac, renal, vascular, podiatric, infectious, this is what matters. I have been fortunate to practice in multiple large hospital facilities and level one trauma centers and to be perfectly honest, I have never felt discriminated against for my degree which by the way is D.P.M. Doctor of Podiatric Medicine, I am a board certified foot surgeon, and have saved hundreds of limbs and lives, and not one of those people or their families care where I went to school, I am the expert, end of story, thats what they want to know.

For my young students, now is a time to be learning and growing, do not start your career believing in a statement that just has no foundation in medicine, you will lose what is so great about practicing medicine the interaction that you have with your peers, the ability to consult and learn from one another and bring that to your practice and your patients. No one can do it alone, we are a team, and you can never win without all the players.

Mark congratulations on your accomplishments I wish you good health, and a prosperous career, but you have much to learn, it is apparent from your post that you simply haven’t a clue, which is why it carries no weight, I would love the opportunity educate you. I can only assume you have had some poor influences that have unfortunately put you at a disadvantage… And by the way it is highly offensive to call Nurses, Optometrists, Dentists or Podiatrists, Para-professionals, we are Professionals, and highly skilled ones at that.

Mark, a fourth year medical student about to begin a seven-year residency, had written earlier:

I can say without compunction that the education of doctors far exceeds that of the various paraprofessionals. There is no doubt that increasing the power of such providers to act and prescribe independently of actual physicians in our medical system will decrease the quality of care. Ordering the wrong tests, or a few unnecessary tests, or missing a diagnosis can be of major detriment to a patient.

But not all budding MD’s are on the same page. James, for instance, also a medical student offers a this perspective:

I think this is a contentious and complicated debate, and the snippet above hardly gives us enough information to have an educated discourse about it. I don’t necessarily disagree with your conclusion, though I think it’s far more complicated that the simple statement that “increasing the power of such providers… will decrease the quality of care.”

That said, please do not assert yourself as a “fourth year medical student about to begin a seven year residency” as if that gives you some credibility to speak on the issue. As a fourth year medical student, you know a lot of anatomy and physiology, a little bit of medicine, and virtually nothing about training of “paraprofessionals”, health policy, healthcare administration, outpatient medicine, insurance, licensure, or the multitude of other areas into which this debate extends.