The Problem With Internship
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.