“What was the best year of your life?” I was recently asked.
That’s easy: 2001. My freshman year of college. I spent that year discussing religion and politics over eggs in diners at 2 AM. I found freedom in the simplicity of dorm life, comfort in the company of friends, and happiness in the occasional beverage. I learned to use a charcoal grill and to hit a Wiffle ball, with great reliability, all the way over the bike path to the Tome Science Building. I developed a close personal relationship with the lyrical stylings of Jimmy Buffett, learned that Eric Clapton’s “Tears in Heaven” is the greatest acoustical guitar song ever, and I remember the weather was sunny that entire year. Man, those were my glory days.
I did forget, however, about that really bad breakup I had early in the year that left me in a moderate-sized pool of depression and self-pity for several months. And I did get called into my advisor’s office because my grades were so low that I could never be a doctor. I fought with my roommate a lot and was rejected by an alarming number of girls. The Philadelphia Flyers lost in a terrible playoff series. Plus, there was organic chemistry. And I just looked it up: my college town of Carlisle, Pennsylvania, received almost 2 feet of rain that year.
Now, as I conclude my freshmen year as a faculty member, I listen to similar stories from my medical elders about the glory days of medicine when doctors were doctors and patient care was all that mattered and everyone loved the hard work and nobody ever complained. I’m told that my generation has a poor work ethic, cares too little, expects too much, and is too lazy to read about their patients. I recently read an essay by a very well-respected physician and teacher, Herbert Fred, bemoaning the failures of my medical training and stating that duty hours are the “worst thing ever to happen in medical education.”1 I’m told this a lot actually. Residents and junior faculty are constantly regaled with anecdotal “When I was a resident…” stories. These stories are most often told to me after I have had a particularly lazy day of using diagnostic tests and not placing IVs. My generation of physicians, you know the type: those lazy, entitled doctors trained after 2003,2 is made to read essays and listen to speeches about how great it used to be. I can’t help but wonder if, like my first year of college, those days seem much better in retrospect than they actually were. Marriage rates of residents were lower, and female physicians were scarce.1 Evidence shows that only a bit more than one half of medical and surgical residents were satisfied with their clinical environment before work hour restrictions,3,4 but I wouldn’t have guessed that listening to them now.
When many of us picture the ideal physician, we conjure up the image of the famous painting The Doctor by Sir Luke Fildes. An elderly man on a home visit, hovering pensively over a sick child who has been laid out on 2 kitchen chairs next to a wash basin while her worried parents watch anxiously in the background. Beside him is his black bag full of medical instruments. The parents stare at him intently, hoping he can save their child. And we believe he can, because he is the doctor. It would be wrong to not admit that part of me yearns to be that romanticized figure. Part of me wishes I had trained in the era in which patients were the only thing that mattered and physicians were so consumed with healing that they never came up for air. But was that really better care? Do we believe that the little girl in the image wouldn’t do better in a modern hospital, with high-tech, diagnostic equipment and a robust array of therapeutic options?
In truth, I read The House of God5 and thought it was funny, sort of a Catch-226 meets medicine. We no longer live in the hospital. I got married during residency, have a life outside of my work, and am satisfied seeing medicine as a career rather than my entire life. More senior physicians may see this as a lack of caring about my patients. In fact, Dr Fred’s essay states that we have entered the era of “doctor-centered” medicine, as opposed to the “patient-centered” medicine of previous decades.1 But this unfair comparison ignores the context of progress. For example, decades ago, aviation safety organizations dramatically changed the way pilots were trained. Among other things, they placed restrictions on both the number of consecutive hours that pilots were allowed to fly and their weekly hours of flight time.7 Today, air travel is safer than ever before.8 I can’t help but see the irony when I read articles about the horrendous changes in our own education and practice. Why does a profession dedicated to healing disregard the improved well-being of its workers? Residents are happier now, and patient safety has not suffered.3,9,10
We have so much to learn from you, the generations of physicians who came before us. If you feel that our physical examination skills aren’t as good as yours, teach us. Come to the bedside with us. Push us. Help us to prioritize our education in a world in which patient care time is limited. Then give us autonomy, allow us to make decisions and to develop our own independent thought processes. Despite the ever-increasing tonnage of distracters pulling us from the bedside (new regulations, paperwork, and electronic medical records) we’ll handle it as long as you stay committed to teaching us how to care for patients and safely allow us to find our own way.11 I often hear stories about bygone medical eras, when residents made all medical decisions and attending physicians, if there at all, were merely consultants.1 I’m told that this method forced residents to actively think and to take a personal interest in the care of their patients. Today, as attending physicians, we hover. We dictate care. We manage the patients, and we leave it to the residents to perform the scut. We consider residents lazy for working fewer hours and entitled if they ask for more responsibility.
I’m a pediatric hospitalist at an academic medical center. Even though I’m “doctor-centered,” I think I’m pretty good with my patients. Although I’m mostly clinical, I do some research and am becoming an accomplished educator. I also feel I’m a pretty representative example of my generation. We’re not as lazy as you think.11 Whether the workweek is 80 or 200 hours, give us the opportunity to care for patients, to be the doctor, and I think you’ll find we rise to the challenge. I often hear the argument that work hour restrictions are delaying the rate at which learning takes place and that junior faculty are emerging who are not fully trained, but I’ve seen no objective evidence of this. In fact, Dr Fred admits that “…a large body of evidence indicates that work hour limits have neither improved nor worsened quality of care and patient safety.”1 If it can be proven, with evidence rather than emotion or anecdote, that our less intensive training is hurting patients then I’ll show up at the next meeting to support you. In fact, I’ll help you collect data for that study. But please stop blaming us for the work hours. We didn’t come to residency demanding an 80-hour week; this was created by you, for us.
I still use a charcoal grill. And I still blast “Margaritaville” with the windows down. I learned a lot about myself that year in college and have used those 2 AM discussions to better understand who I am. I left a part of myself in that year, and I took a part of that year with me. But if I’m truly honest with myself, I would have done many things differently. Why can’t the same be said of medical education? Let’s stop dwelling on how things used to be. Let’s stop comparing. Let’s take the good from the past and combine it with the good of today. Yes, medical education is changing, but new doctors still require teaching and we’re looking to you to continue to provide us with the tools necessary to become the passionate healers and adept diagnosticians that you are. Because, although it may not always be apparent, we have a great deal of respect for your work ethic, your passion, and the medical system you created. You are the keepers of the ideals of our medical forefathers, so pass those ideals on to us.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
- 2.↵Accreditation Council for Graduate Medical Education. Resident duty hours in the learning and working environment: comparison of 2003 and 2011 standards; 2011. Available at: www.acgme.org/acgmeweb/Portals/0/PDFs/dh-ComparisonTable2003v2011.pdf. Accessed November 6, 2012.
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- 7.↵Fact Sheet—Pilot Flight Time, Rest, and Fatigue. Washington, DC: Federal Aviation Administration; 2010.
- 8.↵US Department of Transportation, Federal Aviation Administration. Fiscal year 2011 performance and accountability report; 2011. Available at: www.faa.gov/about/plans_reports/media/FAA2011PAR.pdf. Accessed November 6, 2012.
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- Copyright © 2013 by the American Academy of Pediatrics