How are doctors trained anyway? (Part 3: resident life)

May 4, 2011  |  General

In spite of all its scientific underpinnings, medicine is not really a science; rather, it is an art guided by science. Medical students spend long hours learning about the science of the body, but they really do not become doctors until they have learned the art at the bedside from experienced clinicians. Medical practice is called practice for a reason; we learn it by practicing it in a centuries-old apprenticeship system, which is really what a residency is. As we do so, and again, in spite of the scientific trappings, we imbibe ways of thinking, of talking, and of doing that are as old as Hippocrates. This post will show you that aspect of medicine. Seeing it is fundamental for your understanding of what doctors do and why.

Although physicians learn at the feet of their elders — the experienced practitioners — a young doctor’s peers also heavily influence his training, and through that, his outlook; resident culture is important. Residency is an intense experience that comes at a time in life when most new doctors are relatively young and still evolving their adult characters. In a manner similar to military training, residency throws young people together for lengthy, often emotion-laden duty stints in the hospital. Not surprisingly, and also like military service people, residents often form personal bonds from this shared experience that last for the rest of their lives. Most physicians carry vivid memories from their residency for the duration of their careers.

Recent regulations have limited the maximum number of hours a resident may work each week. These rules came from two sources. One was the common-sense observation that tired residents cannot learn or work well. Common sense, however, cannot change hidebound traditions; what really changed resident work hours was a famous court case in New York (the Libby Zion case), involving a girl who died under the care of overworked residents. The particulars of that case did not clearly establish that resident fatigue caused Libby’s death, but the uproar started a sea change in how residents are trained.

The mandated maximum of an eighty-hour workweek is still long by any standard, but it had been much longer, and many of today’s doctors (myself included) trained under the old system when 110 hours or more per week was not uncommon, with perhaps the gift of every third Sunday off. My own residency program director told us, intending no irony: “The main problem with being on-call only every other night is that you miss half the interesting patients.” So, like garrulous ex-Marines, doctors swap tales of the time that, although brief in comparison to a lifelong career, was extraordinarily important in forming their professional behavior. Generalizations are tricky, especially when applied to such a diverse group of people as resident physicians. This caveat aside, parents who understand something about resident culture will gain useful insights into why many physicians think and act the way that we do.

Residents have come through a pathway that generally fosters intense competition and that values academic achievement above all else. In recent years, medical schools and residency programs have, to varying degrees, tried to emphasize the importance of more humanistic skills like empathy and compassion, and the specialty of pediatrics has been among the leaders in doing this. However, it remains true that physicians are the products of a system that rewards those who excel at competing with their colleagues at how much information one can learn, remember, and then produce when asked for it by a superior.

Resident culture encourages young doctors to appear and act all-knowing and self-confident even when they are not. This skill is often called “roundsmanship” and is inculcated from early on in their training. Residents get much of their teaching during the time-honored ritual of rounds, in which a team of residents and their supervising physician walk around to their patients’ rooms, pausing at each doorway to discuss the case. The discussion typically begins with the resident presenting the patient’s problem and the resident’s plan to deal with it to the assembled group, following which the supervising physician often grills the resident about the case. Residents adept at roundsmanship are quick thinkers and have rapid recall of pertinent facts. Master roundsmen, however, are best characterized as fearless when clueless—they appear assured and in control of the situation even when they are not.

I am exaggerating a little for effect, of course, but my point is to show you how years and years of this kind of environment affect most doctors to some extent. Such a background can cause doctors to seem defensive when questioned, for example by a parent, because doctors spend their formative years defending what they are doing to both their peers and to their exacting teachers. It can also make it difficult for a doctor to admit he does not know what to do with a patient, since physicians are conditioned to regard that admission as a real defeat. This attitude is encapsulated in the saying, often applied to surgeons but relevant to all physicians: “Seldom wrong, never in doubt.”

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