These Are the Days

The Internship Revisited

 

Herbert Fred

Internal Medicine

The University of Texas Health Science Center at Houston

All things are changed, and we change with them.

 

- Lothair 1, Holy Roman Emperor, circa 840 AD

These are the days when interns have reason to gripe. Unless they demon­strate unflagging commitment and indisputable integrity, they risk being fired-sometimes on the spot and without warning. They have no formal contracts.

Their responsibilities are daunting and their schedule grueling. They work every day and every other night. While on duty, they rarely find time to sleep. And when off duty, they must remain in the hospital until all of their patients are in stable con­dition and all studies planned for the next day have been ordered. Consequently, on their post-call days, interns typically leave the hospital about 8 PM, and sometimes not until midnight.

Ward rounds on the inpatients begin sharply at 7 AM, 7 days a week. In attend­ance are the ward resident, the 2 interns, and the chief nurse. Medical students do not participate. These rounds are sacred, generally last 2 hours, and only a bona fide emergency can interrupt them. The intern on the case briefly examines the patient while the resident examines the patient's chart. Results of tests and procedures done the previous day are discussed, and, with input from the chief nurse, the resident and intern make decisions regarding additional testing or consultation, medication changes, discharge considerations, and other "housekeeping" matters. Similar rounds often take place around 6 PM that same evening.

Aided at times by medical students and the resident, interns perform and interpret all admission and follow-up blood counts, peripheral blood smears, urinalyses, stool guaiac tests, and electrocardiograms. Additionally, they start and maintain all intra­venous therapy; draw all blood cultures; stain and examine microscopically all pleu­ral, pericardial, peritoneal, spinal, and joint fluids; apply skin tests; and search for ova and parasites in stool specimens. The intern on call also draws the early morning blood samples from about 20 to 30 patients-the team's average number of patients at any given time. That job-undertaken with frustratingly blunt, nondisposable needles and ill-fitting, easily broken glass syringes-must begin by 5 AM or earlier to be completed before work rounds begin. Interns also fill out the requisition slips for all laboratory tests and procedures and are responsible not only for recording the results in the patients' charts, but also for reciting the results on command.

By carrying out these seemingly menial tasks-called "scut work" in house staff lingo-interns begin to realize the importance of accountability. They learn firsthand the subtle factors that can influence test results. They learn to appreciate other mem­bers of the healthcare team who ordinarily do such work-nurses, laboratory person­nel, phlebotomists, and ward clerks. And most important, perhaps, the scut work repeatedly brings interns into physical contact with their patients, strengthening the doctor-patient bond.

Interns make daily trips to the main hospital laboratory, radiology department, microbiology unit, and other areas to obtain test results, review x-ray studies with a staff radiologist, check on the growth of various cultures, etc. This important rou­tine requires a lot of physical effort, but it ensures timely and uninterrupted patient care.

In addition to the workload already described, interns must squeeze in time for daily chart rounds. During this ritual, the intern and resident scrutinize each inpatient record for missing data, illegible notes, disorgan­ized inserts, and other common deficiencies. ''A sloppy chart indicates a sloppy doctor," the department chair­man says. Not surprisingly, therefore, defective patient records provoke his wrath.

Interns occasionally are discussants at weekly Grand Rounds. This assignment compels them to spend long hours in the medical library searching the stacks for pertinent articles on their topic. In the process, they learn what it takes to research a subject thoroughly, how to read with discrimination, how to critically evaluate what they read, and how to give a formal presentation before a discerning audience.

They also prepare vigorously for teaching rounds, which take place at 10 AM, 4 times a week-3 with an attending physician, and 1 with the chairman. The at­tendings and chairman serve as consultants who simply offer opinions and make recommendations. Responsibil­ity for managing the patient - particularly all decision-making and order-writing - rests solely with the intern and resident on the case. These teaching sessions last 1 Y2 to 2 hours and focus on 1 patient, who is presented, examined, and discussed in detail. Interns must make certain beforehand that the patient is in bed, properly gowned, and willing to have the teaching physician come by. Interns are also expected to bring pertinent literature to the conference room and to have on hand all of the patient's past and current medical records; a microscope with which to look at relevant urine sediments, blood smears, and tissue sections; and an x-ray view box for display of relevant radiographs. The case presentation must be clear, well-organized, and free of ramblings and redundancies. Anything less is unacceptable and will earn harsh reprimands. After the case presentation, the group goes to the patient's bedside, where the attending or chairman takes over. Observing these master clini­cians in action is the best part of the internship.

Once a week, the interns work a half-day in the out­patient clinic. This activity always takes place in the afternoons so that it doesn't interfere with the work rounds and teaching conferences held in the mornings. On the other afternoons of the week, the interns are busy performing work-ups of new patients, tending to patients previously admitted, and completing other assignments and duties.

These are the days when a constant bed shortage lim­its admissions to the very young, the very old, and the very sick. Because no Intensive or Coronary Care Units exist, interns cannot transfer their severely ill patients to a specified area for close monitoring. Instead, they must monitor the patients themselves, using the only monitors available-their own eyes, ears, nose, hands, and brain. This situation forces interns to observe their patients carefully and repeatedly, often for long periods of time. They must also attend every operation on their patients and every autopsy performed on any patient from the medical teaching service. From these various routines, interns gain competence and confidence in their clinical skills, learn the pathophysiology and natural history of disease, and understand when to treat and why.

The highlight of the workday actually occurs at night-midnight to be exact. That's when many of the house officers on duty throughout the hospital meet in the hospital cafeteria for a free meal. Although the food isn't great, the camaraderie is. Furthermore, this respite is just what it takes to recharge the interns' batteries.

These are the days when the internship ingrains disci­pline, stimulates a taste for continual self-education, and promotes mutual respect among all hospital personnel. Indeed, these are the days when good patient care and the education of the intern are all that matter.

What days are these? The days 53 years ago when I was a medical intern in the main teaching hospital of a state university.

Since that time, the medical internship has changed significantly, bearing almost no resemblance to the one I did. Given the ever-increasing emphasis on sophisticated technology, the shrinking of government funding for medical services, and the devastating impact of managed care,' clinical teaching has suffered a serious blow. In ad­dition, medical schools are so strapped for money these days that they force the clinical faculty to spend more and more time caring for paying patients and less and less time caring for medical students and house officers.

Even more disturbing to me as a medical educator is the mandate that was promulgated in 2003 by the Ac­creditation Council for Graduate Medical Education (ACGME), imposing work-hour limits across all train­ing programs, regardless of specialty. 2 Acting to pro­mote patient safety, the ACGME sided with the widely held-but still disputed-notion that sleep deprivation and physical fatigue in physicians lead to harmful medi­cal errors.3-22 As a result, interns now take call every 4th, 5th, or 6th night (but only on required rotations; the other rotations are call free). Moreover, they must leave the hospital by 1 PM on their post-call days, are not al­lowed to average more than 80 hours of work per week, and typically take 1 day a week off

Thus, from its roots as a patient-centered, education­ oriented year of learning, the medical internship has evolved into a laboratory-centered, algorithm-oriented, technology-driven, computer-dependent, Internet-based, "treat first, diagnose later" training program. Conse­quently, we are exchanging sleep-deprived healers for a cadre of wide-awake technicians23 who cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess informa­tion they gather, cannot create a sound management plan, have little reasoning power, and communicate poorly.24

Is this what patients want? Is this what patients need?

Is this what patients deserve? I think not. I also think that unless medical education undergoes substantial reform, things will only get worse.

Meanwhile, we need to find a balance between poli­cies of the past (which emphasized compassion, empa­thy, and high-touch, direct patient care) and policies of the present (which place a premium on high-tech ma­chines and gadgets).25 But whatever the future brings, we must always view medicine as a calling, not a busi­ness, and hold fast to the patient-oriented traditions that have sustained our profession throughout its history.

 

References

1.     Kuttner R. Managed care and medical education. N Engl J Med 1999;341:1092-6.

2.     Statement of Justification/Impact for the Final Approval of Common Standards Related to Resident Duty Hours. Chi­cago: Accreditation Council for Graduate Medical Educa­tion; 2003. Accessed at www.acgme.org/DutyHours/impact Statemenr.pdf.

3.     Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, Mc­Mahon LF Jr., Saint S. Systematic review: effects of resident work hours on patient safety. Ann Intern Med 2004; 141:851­7.

4.     Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, Czeisler CA; for the Harvard Work Hours, Health, and Safety Group. Extended work shifts and the risk of motor vehicle crashes among interns. N EnglJ Med 2005;352:125­34.

5.     Charap M. Reducing resident work hours: unproven as­sumptions and unforeseen outcomes. Ann Intern Med 2004; 140:814-5.

6.     Skeff KM, Ezeji-Okoye S, Pompei P, Rockson S. Benefits of resident work hours regulation. Ann Intern Med 2004; 140:816-7.

7.     Glines ME. The effect of work hour regulations on personal development during residency. Ann Intern Med 2004;140: 818-9.

8.     Griner PF. Residency overwork and changing paradigms of service. Ann Intern Med 1995;123:547-8.

9.     Weinstein DF. Duty hours for resident physicians--tough choices for teaching hospitals. N Engl J Med 2002;347: 1275­8.

10.     Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N EnglJ Med 2002;347:1249­55.

11.     Schroeder SA. How many hours is enough? An old profession meets a new generation. Ann Intern Med 2004;140:838-9.

12.     Green M]. What (if anything) is wrong with residency over­work? Ann Intern Med 1995; 123:512-7.

13.     Bell BM. Supervision, not regulation of hours, is the key to improving the quality of patient care. JAMA 1993; 269:403­4.

14.     Haynes DF, Schwedler M, Dyslin DC, Rice JC, Kersrein MD.

Are postoperative complications related to resident sleep dep­rivation? South MedJ 1995; 88:283-9.

15.     Ryan]. Unintended consequences: the Accreditation Coun­cil for Graduate Medical Education work-hour rules in prac­tice. Ann Intern Med 2005; 143:82-3.

16.     Crausman RS. Residents' work hours [letter]. N Engl J Med 2003;348:664-5.

17.     Mullins MD, Mascolo Me. Residents' work hours [letter]. N Engl] Med 2003;348:665.

18.     Watson PY, Potee R, Blalock A. Residents' work hours [let­ter]. N Engl] Med 2003;348:665.

19.     Rosen 1M, Shea JA, Bellini LM. Residents' work hours [let­ter]. N EnglJ Med 2003;348:665-6.

20.     Steinbrook R. Residents' work hours [reply]. N Engl J Med 2003 ;348: 666.

21.     Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med 2006;355:1339-44.

22.     Barger LK, Ayas NT, Cade BE, Cronin Jw, Rosner B, Speiz­er FE, Czeisler CA. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med 2006;3:e487.

23.     Drazen JM, Epstein AM. Rethinking medical training--the critical work ahead. N Engl J Med 2002;347:1271-2.

24.     Fred HL. Hyposkillia: deficiency of clinical skills. Tex Heart InstJ 2005;32:255-7.

25.     Cooley DA. Foreword. In: Fred HL, editor. Looking back (and forth): reflections of an old-fashioned doctor. Macon (GA): Mercer University Press; 2003. p. viii-ix.