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The Problem With Internship

July 1, 2015

Every once in a while Sandeep Juhar shows up in the New York Times, and it is always a good read.  Today he talked about The Problem With Internship (http://nyti.ms/1IqHf03).  Since like Dr. Juhar my medical internship made a deep and lasting impression on me, akin to post traumatic stress, this topic is near and dear to my heart.  Juhar talks about the duty hour restrictions, limits on number of hours worked consecutively mandated by the Accreditation Counsel for Graduate Medical Education (ACGME).  These rules were implemented after several patient deaths were attributed to resident fatigue.  They’ve also been shown to be largely ineffectual at improving patient safety (http://jama.jamanetwork.com/article.aspx?articleid=2020371).  Additionally, attending physicians, who have completed residency and are supposedly in charge, have no such restrictions.  Witness my own regular weekend 24-hour in-house call.

The Problem With Internship is not that it sucks.  It is supposed to suck, interns know going in that it is going to suck, and they know what they signed up for.  They signed up because they expected to learn and learn and learn.  An intern is sleepless, has no social life, and eats cafeteria food three times a day, all for about fifty cents an hour, because he expects to learn and learn and learn.

The Problem With Internship is that interns don’t learn.  Or rather, they do but in the most inefficient way imaginable.  This is because the work that they do is not conducive to learning.  Interns are so busy writing notes and keeping up patient databases and signing off to each other that they see relatively little of actual patients.  As another of my favorite health writers Pauline Chen reported in 2013 that a study in the Journal of General Internal Medicine found that “interns were devoting about eight minutes each day to each patient, only about 12 percent of their time”. (http://well.blogs.nytimes.com/2013/05/30/for-new-doctors-8-minutes-per-patient/).

In order to learn medicine, or surgery, or whatever, you have to see a lot of patients.  Really see them, talk to them, examine them.  You need to see lots of the common disorders but you also have to see the really complicated patients, the really sick ones, the ones that take two hours to admit in a truly thoughtful way.  When the senior resident is operating on the appendectomy while the intern is updating the computerized patient list, that intern is not learning.  When the third-year anesthesia resident is doing podiatry cases all day while an attending solos on a trauma, that resident isn’t learning.  When the ICU resident knows that he has to start gathering all the data for morning rounds at 3 AM in order to enter it all into the computer, that resident is not learning.  Interns are being used by hospitals as cheap labor, a warm body in a seat or holding a retractor.  The goal of internship should be to learn.  The ACGME should be mandating the hiring of PAs, NPs, and other ancillary staff for paperwork, data gathering, and note-taking.  The ACGME should be requiring large amounts of real patient contact and truly valuable educational opportunities.  Interns won’t mind how many hours they work.  They will learn.

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From → education, Healthcare

3 Comments
  1. S Daniels permalink

    Gotta disagree. Both with Dr. Juhar’s statement that interns are exploited and that PA, NPs, and other professionals should be hired to do the activities that Dr. Leng believes is not part of physicians’ learning needs.
    First – There are some medical staffs at hospitals that exploit residents…that’s true. And it is that – the medical staff not the hospital. When members of the medical staff refuse to respond to their patient’s needs at inconvenient hours, they are the ones who suggest to “call the resident.” When the community based physician refuse to come in to admit their patient at 2 am, they are the ones who tell the ED doc to “get the resident to do it.” Hospitals, have little choice but to ‘exploit’ the residents presence unless they opt for a full time hospitalist staff and close all acute care services to the community based physicians.

    And while I agree that the non-direct care activities are growing every year, delegating them to other members of the healthcare team will not result in residents understanding the ‘business of managing care.’ And it is the absence of that understanding that is often the source of tension between physicians (residents) and their patients. Yes, some tasks can be delegated to ancillary personnel, but unless the residents knows how to document accurately and completely, they may be the eventual subject of oversight agencies; unless the residents know the scope of the paperwork that is involved in transitioning a patient from one level of care to another, they may inadvertently delaying their patients’ discharge; unless the residents know the extent of oversight agencies that regulate hospital activities, they may unknowingly place the hospital and its community at risk; and unless the residents know how to gather data to gain a complete picture of their patients’ progression of care, they may order wasteful and redundant interventions that may place their patients’ at financial or clinical risk.

    Can residency programs improve? Of course they can. Was limiting hours the solution? Absolutely not – it was a knee-jerk reaction to a few tragic incidents. But tragic incidents happen every single day in hospitals resulting in (at last report) 330,000 people dying annually in hospitals needlessly. So instead of the frequent hand-offs, or delegating activities that come with the healthcare territory to others, lets instead restructure the residency programs so they are more meaningful in every way.

    • Sounds to me like you actually agree with me on most of this. Learning the business of medicine, as you call it, is really learning how to navigate the regulations and requirements coming from all sides. While important to understand, I don’t think it should be a primary goal of internship.
      Documentation, now, I’ll give you that. Poor documentation is a problem. But the documentation interns should be spending their time on is complete and legible records daily in patient’s charts that actually convey a solid plan and a good understanding of the disease involved, information that is readily available to all caregivers. Not the patient profiles and to-do lists that every resident has flopping about in his or her pocket and peers at in the middle of the night.
      As to data collection, today’s resident can learn the hospital’s computer system in about half an hour. Data searching is not this generation’s problem.

  2. I still have a year left in med school, but I’ll be an intern soon enough, and I can’t express how much I agree with this post! Great post, Dr. Leng! And I really appreciate your writings in general too. They inspire me a lot! 🙂 I’m still going back and forth between anesthesiology and internal medicine (if I do IM I’d like to subspecialize in CCM or actually I like oncology a lot too even though it’s quite different). Thanks again, Dr. Leng. 🙂

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