Medical education has always been about exposure to the most permutations of illness across the broadest spectrum of disease. That can only be accomplished with repetition. If you want to become an expert in the management of common and uncommon presentations of common and uncommon disease, you have to go to where the pathology is. And guess what. That's not in a stable outpatient clinic setting. A hospital is where you need to be. You aren't going to see that raging case of tortuous aorta or bilateral hydronephrosis at a nurse practitioner run urgent care clinic on a sunny Tuesday afternoon between 1pm-4pm. You're gonna see it when that stoic country farmer, who refused to listen to his wife for three weeks, shows up in the ER at 2 am when the pain becomes unbearable. If you're an intern on July 1st, 2011, you might as well hang out at the urgent care clinic between 1 pm and 4 pm, because you'll get the same experience now that the Accreditation Council for Graduate Medical Education (ACGME) has slaughtered the intern's educational experience.
One of my new partners fresh out of residency has described exactly what the new intern work hour restrictions for 2011 has meant in the real world delivery of hospital based health care. For the last few years, residents could work no more than 80 years per week, averaged over 4 weeks. How about now? Here are the new intern work hour restrictions for 2011. I have high lighted a few of the new rules below.
- Interns can no longer take home call. Ever. Why is that? Because the new rules mandate that PGY-1 (the fancy abbreviation for interns (also known as first year residents) ) must have direct supervision (supervisor physically present with the intern and patient) or indirect supervision immediately available (physically present somewhere in the building). Interns are considered too stupid from answering anything medically related without a supervisor immediately available.
- Interns may not exceed more than 16 hours during a continuous work period.
- Interns should have 10 hours of freedom from work duties but must have at least eight hours of free time between scheduled duty periods.
- Interns must get at least 24 hours off for every 7 day period, averaged over 4 weeks.
- Interns are not allowed to moonlight
That is a brief summary of our new intern work hour residency restrictions for 2011. So how did the University Mecca that I trained out decide to solve the man power issues to comply with these new work hour restrictions?
- Interns no longer pre-round before morning report. If they did, they couldn't...
- Stay in the hospital until they completed their 10 pm shift to take all cross cover pages and admissions. They would have to go home sooner and that would mess everything up.
- Once 10 pm hits, interns must go home and entertain themselves. All internal medicine admissions are now handled by moonlighting fellows looking for extra cash because all the academic hospitalist attendings have no night call built into their contracts. That's awesome.
- The fellows must now take first call after 10 pm if they have an intern on their service. If I was a fellow, I would do everything in my power to avoid interns. They are now worthless, which is pretty equivalent to the status of a medical student on rounds.
May God help us all. If we train under experienced interns and release them into a supervisory role, we end up with under trained supervisors training under experienced interns. These supervisors will become under experienced attendings and the race to the bottom will be codified in the name of patient safety. Interns have just become really expensive medical students (paid for by the Medicare National Bank) while we pawn off patient care duties to the moonlighting allergy and immunology fellow who could care less how thorough a work up they did, as long as they can pawn off the patient to the intern in the morning who got five hours of sleep after closing the bar down on karaoke night. Congratulations interns. You've hit the jackpot. Where else can you earn $50,000 a year as a highly paid medical student with more time for drinkin' and less time for thinkin'?