Who's Afraid of the Big, Bad...Resident?

Today was supposedly the worst day this year to have to go to the hospital. July 1 is typically the first day of the training year for all residents and medical students across the United States, though there are a few programs that start their year in the last week of June. I imagine that most people who know this and have a negative attitude about medical trainees look upon hospital admissions in the month of July with a mixture of dread and disdain.

There have been various writings, from The Underwear Drawer, a blog by anesthesia resident and talented humorist Michelle Au, to an article in The New Yorker by Atul Gawande, about doctors who, with some guilt over the hypocrisy of it, request the most senior person available to attend to their loved ones. I've had a different response. Yes, I want the best care for my family, always, and of course I wouldn't want my young children to be poked endlessly by novices who couldn't get a blood draw or an IV. But when I was an intern and someone asked me where I would take my children if they needed medical care, I immediately named the hospital where I was training, even though I knew residents did all the legwork. I knew my colleagues at the time, and I knew they were unswervingly meticulous about evaluating their patients thoroughly and competently.

And when I was an anesthesia resident and needed to bring my son to the E.R. at Children's for stitches, the senior pediatric resident there, who knew I was an anesthesia resident, asked me if I wanted the attending physician to do the stitches, to which I replied, "No way, I want you to do it." I knew he had been doing procedures day in, day out for the last three years while his attending physician looked on, made suggestions, and signed the chart. So in some sense I was doing the same thing Drs. Au and Gawande wrote about doing, and asking for the most experienced, competent clinician to take care of my son. But I didn't automatically decide that the pediatric E.R. resident was inadequate to the task, like so many people do, a priori.

Having been on both sides of things, I think residents are misunderstood and too little respected. Residents are M.D.'s - doctors - which means they have more knowledge than the average citizen about medical matters. Their education as residents is for acquiring sound judgment and comfort with procedures in a particular specialty - the kind of judgment that can only come from experience. Fellows are those who undertake a subspecialty after completing residency in a specialty. Attendings (short for attending physicians) are done with training.

Someone commenting on Dr. Au's blog compared being approached by residents to being "accosted by idiots." I could go on for a long time about people who make sweeping generalizations about groups (i.e., prejudiced people), but suffice it to say, I found this statement completely offensive in its attitude and content, and unfair to the many resident physicians in this country who provide outstanding care for their patients.

Of course no one wants to be a pin cushion for people learning to start IV's the first week of July, and right now the only way to learn is to practice. As a resident I did let my students start IVs on me, and I wasn't mean or whiny when they missed. The path to perfection is woefully through many hills and valleys of imperfection. And people forget, it's not always a problem with the person performing the procedure. I've seen cardiac anesthesiologists struggle with IVs after decades of doing them expertly. Some people do have terrible, terrible veins. Just like airways. Even the best laryngoscopist encounters that pulse-increasing, difficult airway once in a while.

Personally, and I've written this before, I think simulators are the way to go for certain elements in medical education, like procedures and group dynamics. Repetitive action by muscles makes those muscles and muscle-brain connections more capable. Ask any musician. Of course, in medicine there has to be a STUDY to prove something even that obvious, and those studies exist. They show, of course, that simulation of procedures increases competence at performing those procedures. What a shocker. (Kind of like that study that showed that sleep deprivation - a recognized form of torture, I might add - diminishes the quality of care provided by the sleep-deprived clinician {typically, an exhausted resident}. Like, DUH.) The one simulator I've been dissatisfied with is the intubating mannikin. Intubating that thing is NOT like intubating a human being at ALL.

Sometimes I play a game in my head that involves finishing the sentence: "There are two types of people in the world..." By now I have a long list, which I may post some time, but tonight my mental entry is, There are two types of people in the world: those who respond to students with understanding and patience, and those who respond to them with frustration or contempt. The former probably make better teachers, at least from the students' perspective, in terms of "making connections" with or "reaching" students. I've found that the medical world is littered with many examples of the latter - perhaps because responding the first way takes some genuine humility and a spirit poised for compassion. But there's hope - after all, it's called the practice of medicine.