Many years ago, when I first expressed an interest in a life of medicine, my father set up a time for me to meet with one of his oldest friends who was a physician in the Midwest.
He trained in the 1950’s, and while we talked about his practice and his current life, and what he loved about his job, he also regaled me with stories of his early days in training.
The term “residency” came from the fact that you were in residence, you lived in the hospital, there was no going home, that was your home. That complete immersion obviously had its good points and its bad points. He described a life where he never left the hospital, was probably vitamin D deficient, and ventured into the local town on the sly to “satisfy a certain biological need.” Eew.
He described the master clinicians whose sides he had and trained at, watching them work taking a history, doing physical examinations, performing lab and other diagnostic testing, working to the point of exhaustion and collapse, but learning incredible amounts from people who at the time really knew that art of a proper history, physical exam, and diagnostic evaluation.
The amazing mentors I’ve had in medicine through the years have also been the folks who grew up in a time when they had unlimited time to take care of their patients, and along the way they became great teachers. When you’re not burdened with documentation needs, the ever-present clicking of boxes in the electronic medical record, and the endless paperwork of prior authorization and formulary requirements, in those days, it felt like it was more possible to really take care of patients, to really get to know your craft, and then to pass this information on to the next generation.
The Way it is Today
In contrast, consider the experience that our current residents get in the hospital. Their days are shorter, with strict work hours that require them to leave the hospital like shift workers, and their rotations are chopped up, such that they often spend 2 weeks on a rotation, oftentimes not completely overlapping with either the attending on service who is their teacher, or with the interns and medical students who they are tasked with teaching as well. Every month it’s a different set of rotating characters, and I worry that we’re not getting the opportunities to develop the long-term mentoring and apprentice relationships that are so vital to practicing the art and science of medicine.
In the outpatient world, residents and interns used to come to us for a month at a time, spending 4 weeks straight doing nothing but seeing patients in the ambulatory setting. We would see them every day, supervising them while they saw patients, teaching them in the ambulatory medicine curriculum, and it felt like we really had an opportunity to watch them grow, develop, and mature as clinicians.
Now, because of the changing schedules and structures of the residency, they come to us for only 2 weeks at a time, and then they are off and away for 6 weeks, on the inpatient service or in other electives. This is true for the interns and the senior residents, while the junior residents have no dedicated ambulatory time, coming only for a weekly afternoon continuity clinic, and even then, not every week due to the requirements of other rotations they are doing.
Over the course of a 2-week rotation in our practice, sometimes we may only work with the resident once or twice during that block, so they are really not getting that much exposure to us, nor we to them. If we are only getting an opportunity to interact with them seeing patients once or twice during the 2-week block, how is this enough time — when we are all stressed, overwhelmed, burned out, and fractured in our administrative duties — to really have them see what we do, learn to love what we do, and for us to impart some of the knowledge we have that might inspire them to choose this life?
The Hospital Role
Over the past few years, many people have tried to change these models to create a more compatible and immersive experience for the residents. Some programs are trying to return to longer outpatient experiences, and there are even places that are toying with spending 1 year of residency in the inpatient world, followed by 1 year in the outpatient world.
As I always say, unless you become a hospitalist or an intensivist, most of the healthcare that will be provided is going to be provided in the outpatient world. Cardiologists may do cardiac catheterizations and stenting, and pulmonologists may love doing bronchoscopies, but ultimately they mostly are going to be seeing patients in their office, and patients are going to go home at the end of their interactions.
When I was finished with residency I was really good at taking care of people in the ICU, people just admitted from the emergency room, people teetering critically at the edge of life and death. We could get an IV in anybody, do blood gases and lumbar punctures with our eyes closed, and get people through sepsis and out of respiratory failure and through their acute MI’s and out of DKA. But there was less focus on where the vast majority of healthcare really happens, out here in the outpatient world, in the doctor’s office.
All those patients who survive respiratory arrest will ultimately see that pulmonologist in his office. Everyone for whom the cardiologist does an ablation of a near-fatal arrhythmia pathway will ultimately see that doctor in her office.
Changing for the Better
As we rethink our healthcare system, we need to refocus the base of the pyramid, the vast amount of care that happens in the outpatient world, and we need to both reallocate the training of the next generation of physicians, and provide the resources that help create a world where that sort of life is once again seen as attractive, a viable option, a way to make a life for yourself and medicine.
No one is suggesting that we go back to the life where a resident lived forever in the hospital, because while there was something about learning medicine that way that’ll never be replaced, there was so much more that was so bad about that system that we are definitely never going back.
But if we can build a kinder and gentler system, where interns and residents can find inspirational mentors and teachers, then I think we are well on our way to repairing the future of healthcare.