personally being of the gen X, a generation hated by old school attendings (usually baby boomers), i have not personally been blessed with the financial benifits of the past, or the prestige.

i can say, looking at residency as a whole, things are better. does that mean changes don’t need to be make, no. there is a move in the right direction. as far as prison, not so much. it may feel like it, but it is not. the resident has more power than you think. educators, in and out of medicine, are pressured to pass people. if you look at grade distributions now a days, B is the new C; C is well like a D. to fail someone we need to have justification and can be assured that our grades will be challanged. the same goes for residents. if we feel that a resident is sub par, there are a number of steps that have to be done before we decide to let a resident go. it can take 1-2 years to go through the procees. a majority of the time the thought is why even bother. the juice ain’t worth the squeeze.

overall there are changes in the right direction. the attending has less “power” than you think. truth is, i end up doing more myself just to make sure it is done right.; because in the end, i am responsible. i am a stickler for the rules set down from HCFA, the ACGME, and the RRC. i chose not to test the waters and risk the fines.

Also not to mention that the financial commitment for medical training has increased significantly (in real dollars) since the days when the old-school trained. It’s not unusual to be a quarter of million in debt by the end and, for some specialties, have given up almost a decade of some of the most productive years of your life as a low-wage slave.

Not to mention still again that nobody knows what the future will hold and whether, in ten years, physicians will be just another group of low-payed civil servants.

Also, medicine is no longer a monastic profession full of eager, young, socially dysfunctional white guys who waited until they were done with training to marry their trophy wife. In a society whose principle pathology is the collapse of the family, how on earth can we do anything but admire people who place a value on their families (and want to spend time with them) as opposed to the old days where the physician was expected to be the absentee father.

So this crap about needing more than 80 hours a week to train anybody for anything is just that, crap. It’s a result of the ossified thinking of the old school who are so set in their ways that they just can’t see how inefficient and frankly, idiotic, most of residency training is. The very idea that you need to deprive a young doctor of most of his sleep and family time to have him performing low-skill paperwork tasks that a motivated high school student would do if you paid him a little bit more than you pay the residents is laughable.

Here you have 80 hours a week, that’s a six-day work week of 13-hour days and twice what most people work and I’m expected to believe that a surgery program can’t schedule enough procedures (even those that are semi-emergent) to train their residents?

One day the work hour rules are going to be a law with civil and criminal penalties for their violation and then you’ll see how fast things will get efficient.

as far as the 10 points of residency being a prison, let’s talk about them:

1. Pager Matrimony
resident is attached to his/her pager; the attending is attached to his page (for me cellphone). have your own practice, and you may always be on call. residency is not any different than regular practice, unless you are in a shift work specialty.

for many programs, lecture time is “supposed” to be protected time and therefore, attendings should not be calling during this time. many times the pages are for patient care. in our program, many of the attendings attend the lectures as well or begin cases and clinic by themselves. these are some of the rules coming down from ACGME and RRC.

2. Call and More Call
call is a part of medicine. to accommodate the 80 work week and particular the 30 hr rule, many programs have gone to the night float or home call (if they can). and if you were in house, eating should never be an issue unless you are continuously busy, someone always delivers.

errands are never easy, in a practice or in residency; this is really no different the normal physician life. this is the same for appointments and normal day-to-day life things. in practice you don’t check with your chief resident, you check with your office manager; you may have to cancel a day of clinic or switch a call schedule or cancel OR cases. this actually can be more difficult than in residency because you effect more than just people you work with but also patients lives and schedules. if i cancel a 1/2 day clinic, 35 different people have to adjust. so i try to do things on my day off.

and call, i take more call than my residents (they have home all). i am schedule for 15 days of call in april (regular, adult trauma, peds trauma, and spine)

3. Salaries
can’t really argue this point. salaries are low. but, something that may change things is that there is an initiative for stop medicaid from paying for resident education (i originally thought all came from medicare, but i guess not). this will really change things for resident education. the number of residency spots will most definitely decrease and be replaced with mid level provides. the resident’s salary may increase and the hours decrease, but the number of spots will decrease.

4. Time Off
again, rules are rules, time off is a 24hr period. if a program is not allowing this, they are in violation. in our program, the residents make the schedule. if they don’t have time off, it is their fault. we don’t check to make sure they have the time off.

5. 80 Hour Weeks
i can say that in our program, we are well under the 80hr work limit. it actually is not that hard. the only people who end up working 80’s are the chief residents on the trauma service. lots of trauma.

6. The Hierarchy
again, this is set up for a reason. i am on the surgical end. if an error occurs and the resident makes it, who is at fault? i am. i don’t agree with making it a stuffy “you must salute me” or “you are not of the rank to speak directly with me” but there is a chain of command. intern to chief (or upper level resident), chief makes decision and relays decision to attending, attending’s job is to agree or disagree and advise.

7. Inefficiency
if you have a suggestion on how to make it more efficient, i would be glad to hear it. truth is when i have may clinic that i run by myself, i fill out all the paperwork, FMLA, school notes, prescriptions, place most of my own casts. when i was in my private practice, i wrote all my own notes, changed the dressings, did discharge summaries, etc. when you get into practice, there are many things that you have to do that have nothing to do with medicine. tell me, when do you learn how to do that? when do you learn the politics of getting a patient to rehab or an extended care facility? who teaches you how to fill out the dreaded 10 page FMLA or workman’s comp paper work. who educated you on how to give a deposition? who educates on how to speak with the other care providers (PT, OT, respiratory therapists, ect) in a way that doesn’t make you sound like an idiot?

8. Inbred Social Life
you are exactly right. making relationships outside of the office is something that you have to work at. out side interests have to be worked on and relationships sought out.

9. Contractual Employment
yes you can break the contract and try to find another spot. in some specialties this is hard. it is a supply and demand thing. in medicine, rather easy to do. in say plastics, not so much.

10. Becoming Them
this is a choice. we are all shaped by our own experiences. we choose what will will incorporate into our own practice in personality. see something you don’t like and choose not to do it. how will things change if people who want to change thing do not stay to change them. i have chosen to stay and help make changes. may have not and just complain. i look at it as voting, if you didn’t vote, what right do you have to complain. i recommend to all of my residents, if they are interested, stay in academics and make a difference in medical training.

Maximum Security Prison
ahh, not so much. but it does sound good. it definitely is better and constantly changing. seeing things from the other end i can say things are getting better and the mentality changing slowly. it’s like moving a aircraft carrier.

you make a lot of good points. many are points that have been complained about for years by residents. things are changing and the mentality of the med student and resident is changing. there is more of a sense of entitlement and less patient care. this saddens me. and this has nothing to do with the 80hr work week.