Crozet Annals of Medicine: New MDs in the ED

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by Dr. Robert C. Reiser

Ah, sweet summer is here. I feel like a kid again, with the warm weather and the now- empty UVA campus giving me that school’s-out feeling. Sweet, but melancholic as well; the residents I have come to know so well, the residents I have trained over the last three years, are leaving. Jobs and careers are calling, real life is starting.

Real life is starting as well in a different way for the newly minted MD’s who are starting their internships with us later this June. For most of them this will be the hardest year of their lives with long hours, high stress and seemingly endless demands. Call days can stretch to 30 hours straight on duty and work weeks may go up to 80 hours. These are recently mandated limits, spawned by even longer hours in the past. We “attendings” view these long hours as extended opportunities for learning but the interns are not always appreciative. I hope they are enjoying their sweet school’s-out days now while they last.

I vaguely remember internship year. Our lives were reduced to survival mode. The rules were simple.

1) If you see food, eat it.

2) If you see a bed, sleep in it.

3) If you see a bathroom, use it.

4) Don’t volunteer for anything.

5) Never “pimp” upward.

Pimping is a form of medical teaching in which the attending doctor imparts wisdom by asking a series of arcane questions. The answers are known only to the attending and the two other doctors who have ever read his research (the two chief residents who work for him). It is similar to the Socratic method but more fun. Any one can pimp those under him, but no one can pimp those above. Pimping is not done one-on-one. A crowd of one’s peers must be present but cannot be expected to help. See rule #4.

6) The longer you stay, the longer you stay. Once you have signed your patient’s ongoing issues over to the next unlucky intern, get out of the hospital. Do not check on one last lab. It will require a response that will cascade into hours of further follow up. Remember rule #4.

Overriding all these rules was the number one certainty of internship: you will kill somebody. This was drummed into us throughout medical school and internship. You will kill a patient before your intern year is over. Like a mantra, it was repeated over and over, perhaps in hopes that with enough awareness we could prevent the inevitable. More likely it was to soften the blow when it finally came, to prepare for the reality of medical practice.

Only lately have the training programs finally recognized what now seems obvious. If the interns aren’t crippled by fatigue, fewer errors will result. If the interns are more closely supervised by attendings, perhaps the dreaded fatality by intern can be avoided. Still, we attendings mourn what has been lost in all these humane changes to duty hours. Extended opportunities for learning!