A Year Inside a Medical Residency: Part 1

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As new doctors spend their first days in the hospital, they learn what their lives are really going to be.

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[flickr/JoseGoulao]

I am the director of a medical residency training program. Over the next year, I will share with you behind-the-scenes looks at how we develop and train young doctors. 

Internship -- the famous first year of doctor-hood -- is the forge upon which every doctor develops their knowledge, skill, and bedside manner. I will explore the emotional travails of internship and bring you a better understanding of the training process for doctors in the United States.

***

July. Twenty new interns have undergone more than a week of orientation, getting their ID badges and passwords; learning where to eat, rest, and find scrubs in the hospital. They've been talked at for hours upon hours about residency and hospital policies, the importance of remembering to sleep, and how not to accidentally stick themselves with needles. They are eager to get to work, to become real doctors -- beyond the newly-acquired "M.D." after their name. They are nervous as hell. They want to achieve, to help their patients, and most of all, to avoid making mistakes.

Is it true that July is the worst time to be a patient in a hospital?

You can find evidence on either side of the argument. (Here's a yes, another yes; a no. A recent piece in The New York Times by nurse Theresa Brown generated a lot of pushback when she opined that new doctors make more mistakes.) 

There is certainly merit to the question. What other profession routinely kicks out a third of its seasoned work force and replaces it with brand new interns every year? To be sure, running such a training program takes a certain amount of stamina and skin-thickening to handle the yearly transition.

In my view, we provide greater supervision to our interns and residents in July and August, when the days are long, spirits are high, and the trainees are hungry to learn and hear feedback from the faculty. In fact, we double up on the number of senior residents (second and third year trainees) supervising our care teams on the wards. So there are actually extra pairs of eyes and hands there to facilitate both patient care and teaching.

As supervising faculty, we too are sensitive to the newness and wonderment of our interns and strive to be patient with what are sometimes rudimentary and repetitive questions. As a program director, I believe in the importance of being scheduled to work directly with new interns early on in the academic cycle, both to form firsthand opinions of their talents and to role model the type of doctor that I want them to be.

My anticipatory emotion is often dread. Who wants to ride up along such a steep learning curve yet again? But once they show up, their sheer enthusiasm and willingness to throw themselves into their new roles overcomes my disdain almost immediately. Perhaps it's a reaction proportional to their collective fear.

My experience with intern disasters is that they seldom occur in July. They tend to happen later in the academic year, during the winter months, when interns have shed their fear and become more confident. They tire of asking for help, not wanting to appear "weak" in the eyes of their seniors. Not recognizing the limits of one's own knowledge can be a fatal flaw in this business.

At one of my previous institutions, an intern confidently decided that she did not need help removing a large-sized catheter from a big vein in a patient's chest. (IVs and such "central lines" are removed before patients are discharged from the hospital, except in select cases.) Cavalierly, without noting that the patient was on blood thinners, she yanked out the line without proper precautions in place, precipitating a gusher of blood that transformed the patient's room into a sanguinous pond.

The patient was rushed to the operating room and ultimately survived. The retrospective on the case was that the intern was not properly supervised and made errors of both omission (not recognizing the patient's anticoagulated state) and commission (taking out the catheter without proper guidance).

I offer examples like this one to encourage my residents to follow procedural checklists to the point that safety is an ingrained behavior rather than solely an externalized concept. I also want to remind them that judgement errors can happen to any of us.

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John Henning Schumann, MD, is a writer and physician based in Tulsa, Oklahoma. He runs the internal medicine residency program at the University of Oklahoma School of Community Medicine.

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