Thursday, June 27, 2013

Are millennials cut out to be surgical residents?

When you hear this story, you may wonder.

Recently in a surgical residency program somewhere in the United States, the residents requested a meeting with their program director and surgical department chairman to discuss a concern they had.

A few of them were upset because during a 31-day month, one resident on a three-person rotation ended up working an extra night of call.

6/28/13 ADDENDUM#1: The residents who complained included some non-designated PGY-1s who were hoping to be converted into categorical residents if any such positions became available. This would not be perceived as favorable by those in charge.

I know that old guys like me aren't supposed to say things like this, but if residents had approached my chairman with a complaint like this, he would have thrown them all out of his office immediately.

Residents were summarily fired for lesser offenses than that too.

Despite my previous post about a Harvard Symposium that suggested we should train residents like Navy SEALs, I know we can't turn back the clock.

But people, there is something really wrong when residents start haggling about the number of days worked.

What's next? Requesting an extra hour off because you worked the Saturday to Sunday overnight when Daylight Savings Time ended?

I didn't see anyone volunteering to work an extra hour to compensate for the night the DST begins.

OK, tell me I don't understand this generation of residents. Tell me I'm out of touch.

But you won't convince me that there isn't something wrong with complaining about an extra day of call.

6/28/13 ADDENDUM#2 As pointed out to me in comments on Twitter, my post does not pertain to all millennials. I acknowledge that such a generalization was unfair.




48 comments:

David Milgrom said...

As far as I'm concerned an extra night of call is an extra potential for scrubbing into an interesting emergent case ans getting more experience. Not to mention the overtime.

Anonymous said...

The truth is there is something wrong with the f&;$ing baby boomer generation of attendings. They screwed up our field thenexpect is to do their scut. Look in the mirror before you publish stupid shit. As residents and young med students there should be a revolt to rid of attendings that have over treated without guidelines and hold them accountable.

Skeptical Scalpel said...

Luckily, I'm not a baby boomer. Perhaps you could elaborate on how they "screwed up our field."

And I'm not sure what you mean by "expect is (I assume you meant 'us') to do their scut." What scut are you referring to?

Skeptical Scalpel said...

This is a comment from Libby who was unable to post it herself due to technical difficulties.

"Angry Anon? As a patient I would suspect you of having a 'god complex'...and you are behaving like a stereotypical millennial baby. Yes, the boomers screwed up. We raised a bunch of whiney kids who believe they're entitled to things without working for them. Knowledge is more than what you read or skim over in textbooks, websites or patient charts. It is gained most through experience. And experience is gained by being there for when an issue or condition or situation occurs, not by sitting in your undies on your couch in your apartment.

"I see every day at university students who choose to not do an assignment because they deem the tangible benefit is not worth the effort. They do not understand that the richest benefit is in the process of doing.

"Residency is only a short amount of time, make the most of it. Seek out as many situations, conditions, issues, what-evers as you can squeeze into the time you have. It will make you a better, more knowledgeable doctor. If you are extremely lucky, you will have an enriching day of learning EVERY day you come to work looking for knowledge."

Nathan Cleveland said...

I think what anonymous meant is: "The truth is *that* there is something wrong with the f&;$ing baby boomer generation of attendings. They screwed up our field then*_*expect is *us* to do their scut *work*. Look in the mirror before you publish stupid shit. As residents and young med students there should be a revolt to rid *us* of attendings that have over*-*treated without guidelines and hold them accountable." I count 6 grammatical/punctuation errors in 4 sentences... But then again, who cares? It's just meaningless scut work, right?

Skeptical Scalpel said...

Thanks for the analysis. We all make typos, but 6 in 4 sentences? As Nathan points out, attention to detail can be important.

Anonymous said...

This one from new Delhi, India. The situation is pretty much the same here. I am a resident in the surgery deptt here. And if we go to our boss for an extra hour worked complains, ill pretty much spend the next month out of the or. No defined work hours here, we have done 72 hours in 4 days and still attended or the next day.

Vamsi Aribindi said...

Longtime reader but first time poster here-

I hope the anonymous above meant to be satirical. I'm a medical student myself, and I'm actually against Duty Hour limits. I come from a medical family- I have something like 10 aunts and uncles who are doctors, not to mention my mom who got through an Anesthesia residency in the early 1990s while pregnant with my sister. The way I see it, if she can work 100 hours a week to learn her trade so can I.

I've recently taken some hope. I happen to be co-president of the AMA Medical Student Section at my school, and we hosted a Duty Hour limit debate- the ACGME representative strongly hinted at change that would allow individual specialties more flexibility in determining restrictions. Here's hoping my residency(in 3 years!) won't be limited by the stupidity of the 2011 rules at least.

Anonymous said...

if you're a questioning person you would realize how much over treatment and non indicated treatment there is in our field. Oh really you hip is hurting lets replace that hip. Oh really you have an enlarged paratracheal node stable for five years after treat lets give chemo. The god complex is people like you who fall into line with what your seniors tell you even when it's unethical and wrong. Our field is screwed thanks to older attendings so they could make a couple extra bucks. Is there any wonder there is an erosion of our status as physicians? Train like a navy seal my ass.

Ian M. said...

A few smelly cat turds don't ruin the whole flower bed. I don't deny that my generation has many entitled brats, but I know that doesn't represent the entirety. I hope for everyone's sake that some of us are cut out to be surgical residents. It sounds like they need some "perspective".

Skeptical Scalpel said...

Resident from India, thanks for your perspective. 72 hours in 4 days is a bit much, even by my standards.

Vamsi, I hope you are right. Some flexibility would be helpful and most welcome.

Anonymous, there is no doubt that some doctors over treat patients. The system is far from perfect. I had no control over its evolution to the way it is now. I don't understand your reference to a stable node getting chemo. Who does that? And chemo would not be given by a surgeon anyway.

I think you have a serious problem. Tomorrow, you should read the two comments you posted and try to figure out why you are so angry. I hope there is counseling available at your program.

Anonymous said...

Look it's not you who has these issues I get that. But the whole culture is messed up because of it and we're all just pawns in a very dirty game. It's time to unionize against the interests and time for us to care for each other not berate others like you're doing here.

Vamsi Aribindi said...

Honestly though, the problem isn't even duty hour limits. From what I hear, it's the sheer amount of paperwork. If interns and residents were actually operating and taking care of patients for 80 hours a week, that may not be as big of a deal. But if they spend 20 hours taking care of patients and 60 hours charting... how can they possibly learn?

What was the paperwork like back in your day?

Skeptical Scalpel said...

Ian, I agree. I've already been taken to task on Twitter for my sweeping generalization.

Anon, I don't see doctors ever having a national union. It's not our nature to band together for the common good.

Vamsi, the paperwork is indeed daunting now. It wasn't nearly so bad 20 years ago. We have been turned into cleric personnel for hospital billing departments and third-party payers.

Two recent studies have shown that interns spend only 12% of their time with patients and 40% of their time on computers. Here's a post I wrote about one of those studies. http://skepticalscalpel.blogspot.com/2012/08/what-do-interns-do-when-theyre-on-call.html

Anonymous said...

I am an ICU doc, not a surgeon, but I've been around the block a few times.

Spending time on the computer looking up labs, scans, and evidence-based interventions is less sexy than ripping into an acute abdomen at 2 in the morning. I would argue that the former is just as important as the latter experience for a resident, even a surgical one.

You can spend half an hour getting the specifics of chest pain, family history, etc, etc., from a 50 year old patient, or you can get his serial troponins and EKG's off the computer. I think a lot (us) old farts are not rational in our pining for the good old days.

Vamsi Aribindi said...

To the Doctor who posted above as anonymous:

That would be true- but I'm referring to the soul crushing amount of authorizations, releases, and checklists that have to be filled out to do anything. If you're interested, I recommend checking out the new documentary, Code Black, produced by a senior ER resident at my school (USC).

It showed one resident so tired that he was thinking about (and berating himself for thinking about) not doing an LP on a patient that needed it (on camera no less) because of the 6 forms he has to fill out to do it. Granted, it would be ridiculously ironic if this had the secondary effect of reducing unnecessary procedures. Still, when someone has to fill out 6 forms to do an LP, and is filling out releases and checklists instead of thinking about diagnoses, are they really learning?

Anonymous said...

It's not in the nature of older docs to band together for the common good. Your times have passed. You guys made your money move aside and let real medicine get done now. Unionization is the future and we will demand better hours like nurses and ancillary staff that profit from our system with no abandon.

Skeptical Scalpel said...

Anon ICU doc, I see your point, but I think a lot of the computer time turns out to be checking boxes that are irrelevant to the patient's real problems.

Vamsi, thank you for supporting my comments to the ICU doc, especially the myriad forms that add nothing but documentation to the EMR.

Other Anon, I eagerly await your deliverance of "real medicine" from the abyss you have been handed by us old guys. I also look forward to the advent of your powerful union and the great changes it will bring forth.

Anonymous said...

thanks skept for your support. That you would post about kids new to the field that are trying to live their lives in a way that is stripped from them because of our money grubbing medical system that rewards your generation displays your class. The future that awaits these poor debt laden residents is about to hit with a ton of bricks. Medicine is not what was promised; We've been hijacked bc the older generation wanted to make a few bucks. But go ahead, keep posting cute thoughts about how your you colleagues can't handle taking call when they're breaking their backs to make you look good. And go ahead count my spelling errors, avoid the real issues

NeuroTrumpet said...

To the original Anonymous-

"Us vs. Them" mentalities get us nowhere. If you are in the medical field, then surely you're aware that the world is not black and white, but rather shades of gray.

Certainly, many "older" docs exhibit some traits you have caricatured, but there are countless more who epitomize good medical practice and paved the way for us new physicians. More to the point, what makes you think there aren't as many (or perhaps more) bad eggs among the newer generation? I am frequently astonished that some of my age-matched colleagues were able to be accepted into medical school and subsequently graduate.

I agree with Skeptical Scalpel that you should search for whatever demons are motivating your contempt for your mentors (and if you are not a physician yourself, then frankly you have no right to make those comments in the first place).

Henna said...

Anonymous--what "was promised" to you in medicine?

Skeptical Scalpel said...

Thanks Neuro and Henna.

I would add that there are many people who make a lot more money than doctors in the US medical system. To mention a few: hospitals, hospital administrators, insurance companies, insurance executives, drug and device manufacturers, lawyers.

Anonymous said...

I am a physican so I live this. You're right I have no idea if we will be different but I do know the system is going to swing so far the other direction that our autonomy will be stripped. The older generation was complicit in allowing this if not playing an active role. Your rvu based system has ruined residency across the country. We have no vocal physician leaders, only vocal economists. We have physician leaders that write blog posts disparaging future physicians instead of focusing a blog on the future. Older docs are complacent and not activists like our forefathers wanted us to be; that should be the topic of this blog post.

Skeptical Scalpel said...

I've written many posts about the future of medicine, medical and surgical education and other aspects of medicine. Unfortunately, I have no power base and no influence on those who make policy. Even when I was an active program director, I was not appointed to any committees or positions of power. I was told I was too outspoken.

It's not my RVU-based system. Google the history of RVUs and see for yourself. And I'm not sure how RVUs have ruined residency. Maybe you can explain that.

Besides commenting here (which is not likely to have much impact on medicine either), what are *you* doing to bring about the changes you seek?

artiger said...

Hmmm, I was born too late to be a boomer, but I did my residency before work hour limits. Is this where I complain? Also, one of my co-chief residents had a baby during the final year. My goodness, I had to take more call than someone else. I have been traumatized by that ever since.

One thing that I learned in med school and residency is that life just ain't fair. I can't believe that a resident would complain about one extra day in a month; talk about no self-respect. Scalpel, did you hear that from the program director, or was it more third hand (not that I doubt you)?

As for the other nonsense that has polluted this thread, I too am disappointed in how medicine has evolved; it is not really at all how I thought it would be. I have at times regretted it, and yeah, maybe some of this was set up by my predecessors, but it does no good to blame and shame. Still, I make a good living by many others' standards, and I am pretty much guaranteed to always have a job (which seems to be pretty important these days). For that I am grateful.

Skeptical Scalpel said...

Artiger, thanks for commenting. Yes, you may complain here.

I heard the story of the complaint about the extra day of call directly from the program director.

Your last paragraph shows a lot of common sense.

Chris Porter MD said...

An alternative framing would be to ask if yesterday's surgeons would be cut out for residency and the practice of surgery today?

I think of the surgeons who trained me and wonder how they would fare today with team-based care, documentation overload, flattened hierarchy, being compelled to lie about hours (or leave the hospital on the clock), narrowed practice breadth, longer delay in financial reward, closer supervision, competing responsibilities at home, and a sharper eye on professionalism and behavior.

The changes invite trainees of a different demeanor than prior generations, I believe.

Skeptical Scalpel said...

That is a good question. The answer is, we probably aren't. It's one of the things contributing to burnout.

artiger said...

Scalpel, how, if I may ask, did the program director respond to the complaint? Did he share that with you?

I don't think I need to ask how he felt about the whole thing.

Anonymous said...

Look skept I'm sure you're a good person, don't get me wrong. But this blog post is a microcosm of what is wrong with old and young physicians. They see one or two things and start generalizing to populations. They make unsubstantiated treatment decisions based on similar generalizations and not data (or don't collect data, that is a separate issue). Unsurprisingly those decisions happen to benefit said physician monetarily. You are all saying there should not be a blame game tone in my posts. Just ask yourself how you felt when the credit crisis took place and the blame that was placed on hedge fund and I bank managers. Alot of people in our field deserve the same for overtreatment and treatment perversification, some more some less. It is the same boomer generationalists and it is an equal scandal. Those of you that have stood by profiting not saying anything unfortunately take heat too. And that your prior response would be 'well other people make alot more money than doctors' flys in the face of and is an impediment to true change.

It is true we are heavily underpaid for the skill and specialty we bring but we are unable to unionize and make demands bc physicans like you want to worry about if a 27 year old wont take an extra call while other unions in the hospital have made out like bandits and protect their colleagues. Why aren't there nurse blogs asking your same question? Because they protect their own while our field berates it's own (well characterized by neuro trumpet above who can't believe his colleagues got into medical school; they say the same about you bud).
And lets not worry about what I'm doing; nothing is changing for the better until your generation steps aside or finds its moral compass fast. You said you weren't appointed to committees bc you are outspoken? You're speaking about the wrong things.

NeuroTrumpet said...

Anon-

That's a fair, if ad hominem, assertion. I can't please everyone, so odds are some of my colleagues view me negatively--but I fail to see how this is germane to the contemporary medicine workforce or generational divides. In fact it only reinforces my point that this is a constant: there will always be a few bad eggs in the batch. The error is one of a representativeness heuristic.

As for "berating our own," this is a severe description of a generally good thing. Professionals should be highly critical of themselves and their colleagues to maintain a high standard. Being nasty about it is obviously unproductive, but we should hold each other accountable. In your own way you are doing this, as is Skeptical Scalpel in his. On the whole, my impression is that we are largely protective of one another and, more often then not, work collegially in the best interests of our patients.

Change is good. It's already happened, and will continue to occur (granted, at a glacial pace). Your dissatisfaction with the status quo is part of the impetus, but without action amounts to little more than hostility. Finger-pointing and blame-gaming won't get us anywhere, so let's keep the discussion alive and work together to move forward.

RuggerMD said...

Well, I want to say "Thank you Skeptical Scalpel" for making my decision.
5 yrs ago I left academics and teaching and have been recently asked to come back.
In my decision making process of returning, I kept coming back to my same worry that trying to teach students and residents drove me crazy because of many of their attitudes and lack of self determination and learning.
Well, SS, this post drove the nail in the coffin. I was right, I don't want to return back to the pain.
Thanks.

Skeptical Scalpel said...

Artiger, I have not heard how this issue was resolved. I will let you know.

Neuro, well said.

Rugger, I quit the resident teaching grind 5 years ago too. No regrets. Now I just watch from the sidelines as things disintegrate.

Anonymous said...

this post started out with skept berating poor residents that are half his age and now we've come full circle as he says residency (and residents, I'm sure) are disintegrating. Did you not learn anything from your losing side of the argument on this thread. You really should look in the mirror and ask 'should i continue to treat patients? have i really made a difference or have I just profited handsomely from a system of no checks and balances?' You and your colleagues should be put on trial for over treatment and mistreatments in the face of profit. Yet here we are, berating poor overworked residents who are growing a spine to speak up unlike you frauds who have ruined the field we will inherit.

Anonymous said...

I don't think resident training is disintergrating. Yes, to those who trained under the "old" system, and you're watching things now I guess I can understand how it can look like things are falling apart. I feel that attendings who leave teaching are those that can't adapt to change- change in culture, change in generational attitudes towards work and life- a change that is inevitable and will keep on going. The failure will be in our inability to adapt to these changes.

I'm training under this "new" system and I think we'll be ok. But I'm pretty sure I'm going to find the next generation of residents (~20yrs from now, when they're working 30hrs a week) to be weak, whiny ass punks! And they'll probably tell me the same things I'm saying here...

Skeptical Scalpel said...

First anonymous: With all of your rants you have yet to offer one constructive or factual thought. But I do appreciate that you continue reading. Other than you, who says I lost the argument?

Second anonymous, you may be correct that things will be OK. I hope so. I know you are right that in 20 years you will be complaining about that crop of residents.

Anonymous said...

skept you lost the argument as soon as you decided to post something whiny and irresponsible like this. You are part of a class of physicians that do not think they can be wrong and that everyone will agree with them. You are frauds, and should be tried in the court of public opinion. That day will come soon, Im sure. I told you, there is no use offering constructive ideas when your pompous generation is still around. And I ask again, where are the physician leaders in your generation? Where are the voices that our field needs in these times? It's obvious - silently making their money before things dry up. Why haven't you blogged about that?

Skeptical Scalpel said...

Talk about whiny. Go back and read your own comments.

So there is no use offering constructive ideas? That's a great attitude. Or is it that you have no constructive ideas?

Obviously, we disagree. There is no point in discussing this further. Because it's my blog, I get the last word. If you want to continue your tirade, start your own blog.

Anonymous said...

I am applying to residency this year, I do not intend to offend anyone who has posted on this topic and I apologize if I do. I do not understand going into medicine with the intent of having a 9-5 type job. I do not understand cutting resident hrs to the detriment of our education, along with the possibility of extending the length. I am not just speaking on surgery residencies. I also do understand following those who came before us whom laid the foundation for medicine in this country and what I believe, even with its struggles, still offers the greatest medicine in the world.

I have a 3 children whom I love and dearly miss and a spouse whom I love and dearly miss, but I make the sacrifice for them and others so that I can be what a started to be, a physician.

I watched my older brother go through the system in the early 2000's he worked morning, noon, and night then, he works morning, noon, and night now, and he is not a surgeon he is primary care and works to the best of his ability for his pts and his family, along with covering shifts in the ER, hospitalist wknds, and his practice.

I do not understand, why do this if you arent willing to sacrifice to be the best.

Velva said...

This is cool!

Anonymous said...

This is dr.muchogusto from twitter. I have a different perspective on this topic. I would like to go to the origin of millennial problems. First, these issues are created from day 1 of medical school. We make our medical students have this sense of entitlement and the arrogance of awarding them for being selected as a MD candidate is just horrible. I have observed medical students go from being stellar 4.0 undergrad students to just average med students. We offer this comfort zone to medical students once they arrive that they will be pushed along. With all the law suits in the past, grad schools make sure all their students pass and get awarded their degree. It seems the same work ethic students previously had to get into medical school is lost, not everyone, but there are a few. So what do we do we help this kids pass, we do not discipline them for shooting for avg, and we still pat them on the back. End of 2nd yr comes, MS takes the boards, crams for the test using one stupid review book, and scores 240 plus. Wow, pat on the back, here why don't you apply for optho or ortho, etc. Now this 240 student completes 3 yr clinical rotations, 4th yr comes along. Hey where is Mr 240, he should be checking on so and so patient. Oh, he or she is taking it easy because optho dept has told them they are committed to he or she to match into their program. Why should he or she work so hard when they are setup for a great residency. Complete waste of a 4th year, again entitlement, spoon feeding the student. What happens next MS arrives for first day of residency, comes to find out because of the new hours limitations his PD balances his schedule by starting he or she in a one month challenging rotation, then the second month easy. New resident starts second month of easy rotation, hey Mr attending, I'm going on my one week vacation because I get 4 weeks off in a whole year and this is my easy rotation. Mr attending, Okay, if you say so but I really need your help, can you please come back a little earlier. New resident, oh no, I made plans to go to vegas with my girlfriend and we already bought tickets. This is just examples how from year 1 we baby students and it all carries over. We need to be harder on students, make them more accountable for course work in the first two years. The PD's got it wrong, you cannot judge character based on a high step 1 score and totally dismiss the first 2 yrs of med school and the fourth yr when students become lazy. Listen, I'm truly exaggerating here, but you understand what I am getting at. Lets go away with the P=md. No P does not equal md, work harder. I know there are the other really motivated students who want to be neurosurgeons or want to go to top programs but this is a small percentage of the whole class. As a chairman described above, I am sure he could do anything about it because if he fired the resident, there is risk of being sued, etc. There is too much legal action now a days, what is a PD really to do. If a resident failed absite or did something extreme, then they could be fired. In this scenario, all he could say is we will work it out, but I wish you were stronger, etc.

Skeptical Scalpel said...

drmuchgusto, thanks for the comments. You raise some interesting points. I hope some of your contemporaries respond.

Anonymous said...

Good morning Skep Scal. Its Drmuchogusto. By the way my ex of resident, fellow and attending arguing about vacation schedule is a true story. Where I am at to balance hrs the gs resident does a few weeks of a hard rotation then a "easier" one. Guess what rotation was considered easier lap/endo surg. Going back to our debates about how future surg lacking fundamentals, lacking confidence after graduation. Now you know why the graduating resident needs to do a fellowship in lap, haha. Putting all jokes aside, you and I have agreed the surgical curriculum needs changes. We also have agreed to a point that the 4th yr of med school is a joke. In addition, I feel strongly that the MS curriculum needs a large overhaul. I know a lot of my peers will disagree. This whole bs we produce quality doctors, this is our goal, yada, yada. Listen, there is no truth in this. Schools compete with each other who got all those prestigious spots for residency in all specialties. So I hate to insult PMNR, but if you got a student who matched in the number 1 PMNR program, this would be bonus points to the school. You get someone who matched Mass gen IM, ucla peds, more points. To obtain these positions it comes to one thing that test score. Until we don't change that and make students accountable for much much more, you will have PD's like your friend telling you about someone complaining about call. 10-15 yrs back, gs residency was tougher, people would not complain about vacation schedule. Now you got gen surg residents who actually have a exercise schedule. It is all great to a point, a little bit of a balance should be there. It of course does translate in better quality of care, when you have workers who are more fresh and happier in general. The point is we have promoted the bellyaching, laziness, and that lack of intensity residents once use to have. Someone commented earlier, would the older gen surg make it today. I really do, because whatever nonsense exists today you guys were hardcore men/female surgeons. I am pretty hardcore myself, I live in the hosp and I still go enjoy my time w others in the hosp. Not everyone is like this. Also, I apologize for my horrendous writing and typos, typing million miles per hr. Thank you.

Anonymous said...

Good points DrMuchoGusto.

Skeptical Scalpel said...

I agree.

Anonymous said...

I am a biomedical engineer. I did research in the 1990s in neuroradiology and got to know and observe radiologists, surgeons, and medical students. The typical hospital back then was like a caste system with attending physicians bullying over-worked interns to the tandem of 100+ hours a week. 36 hour shifts were common. Extremely snobby, arrogant doctors like the one portrayed by Alec Baldwin in "Malice" were often encountered. Parallel to that was the malpractice crisis in many states that evolved. After becoming a biomedical engineer I worked for about 10 years then earned a 2nd master's degree in public health. I learned that the most clinically and economically efficient practice is in primary care rather than a specialty like surgery. If a family practice doctor convinces a patient to lose 20 lbs and quit smoking, that saves much more money and enhances health. It's more efficient than a heart surgeon operating on such a patient after an aortic bisection while charging excessive fee-for-service. Heart surgeons in the 80s were often millionaires despite risky invasive procedures that are, in many cases, no longer done. To be fair, I think minimally-invasive surgery has evolved to make surgery safer with less complications. But there is a shortage of primary care doctors in an era of healthcare reform.

Skeptical Scalpel said...

Thanks for the comments. The challenge is getting the patient to follow recommendations to eat healthy and exercise. As long as there is no incentive to do so, cardiologists and heart surgeons will stay busy.

Anonymous said...

Agreed Skep. As long as we also have businesses that make money that pay off legislators, that's what happens.

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