The new and the old

Check out this article in the NY Times (may require free registration) about two radically different types of young doctors this attending had to deal with recently. The old and the new.
The new was a 9-to-5’er, didn’t do “nurse’s work”, didn’t stay up late worrying about his patients, got to work at 8am and took long lunch breaks and was never late for anything and rarely stayed after 5pm. He had nothing but a Palm Pilot in his pockets.
The old was a more traditional intern, in by 6am and there until late at night, often signing out after 80 hours and working informally thereafter. She cared deeply about her patients, fretted about them at home, cried when they suffered, had pockets stuffed with reference books, notes, and gear.
Who knows if this is a trend (toward him and away from her) or not. Anyway, interesting little commentary.

Hi there,
I will give you another scenario: My attending surgeon was on call this weekend. He practices at three hospitals in Cleveland. He started at 0600h on Saturday, rounded on his six patients at one of his hospitals and wrote orders. He finished there and came to my hospital where he had a case with me that took three hours (it is now 1300h) and rounds with me ( I had rounded on all of his patients and had written orders (I was post call) so it took almost 2pm for him to get our patients covered. He then has his third hospital to go to, see his patients (no residents there). He got home around 6pm but got another call from my hospital where he came in to do a 4-hour case. Now it is after 10pm when he finally gets back home. He gets called off and on through the night by residents and nurses. He meets me at 0600h the next morning to take the person that we did earlier back to the OR for a “second look” (no mistake but part of therapy for this type of condition). We finish the case around 11am then we round until 2pm on all of our patients. We get two admissions which I get worked up while he finishes rounds at the other hospital. He meets me at 6pm to take one of the new patients to the OR.
Over the course of two days, he has gotten about 3 hours of sleep and worked constantly the rest of the time. He has done more that 4 emergency cases and he has been supervising me (post call and operating). If he doesn’t see his patients, he doesn’t get paid or even worse, he gets sued for neglecting his patients. All of this is over a weekend of call from 5pm Friday to 5am on Monday. On Monday, his regular schedule starts where he has office hours. He gets home around 6pm on Monday and is able to get some sleep on Monday night interrupted by calls.
It isn’t residency folks, it’s real life where you are going to work the long hours. Do you honestly think that you are going to be sitting in an office where money is going to be rolling in? How do you expect to pay for that office? How do you expect to pay your malpractice? Some of you might actually have a loan or two that you need to pay off too.
I don’t care what kind of intern or resident you are or how many hours you work during residency, you still have to make a living when you get out into practice. It won’t be shift work then. I would rather ramp up during residency than get thrown in as an attending and make no mistake, you will be working more than 80 hours as an attending or you will be starving.
Change the system? The public isn’t interested in tort reform that would lower malpractice premiums or foster competition among the insurance companies that provide malpractice insurance in some states. Lawyers still see suing physicians as a way to make a very quick buck. If you look in the Cleveland phone book, there are more malpractice lawyers than physicians. There are million dollar settlements where the patient sees about $12,000 and the lawyer gets the rest.
No matter how much that intern runs around after her patients, cries and calls back, she is still very likely to be sued within her first year of practice. The other intern is not likely to make enough to pay his malpractice premiums because you can’t bill for hours on your lunch break.
As you rub your hands gleefully looking at hours being cut during residency, along with pay too, you need to look beyond residency to what you expect to take home. You are not going to like what you see and in many states, you are not going to be able to make a living. It will be quite a shock when you are standing there newly minted from residency lamenting about your hours.
Natalie

Amen to this post! it is amazing how many pre-meds and medical students “assume” that once they are done with residency the hours will decrease exponentially! I have spoken to many physicians covering a wide range of specialties and ALL of them work a LOT OF HOURS. I do not know where folks get this notion that medicine is a 60 hour work week…

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I have spoken to many physicians covering a wide range of specialties and ALL of them work a LOT OF HOURS. I do not know where folks get this notion that medicine is a 60 hour work week…







On this idea of time worked, I think a lot of people don’t understand that when a physician says they work part-time, that really means 40 hours/week!





Another important question is does a “lazy” doctor work 80 hours/week or less and a “hard-working” one more than 80 hours/week?

Actually, most PT physicians actually work about 60 hrs/week!

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Actually, most PT physicians actually work about 60 hrs/week!


Perhaps you’re right. But I find most of the “problems” mentioned in the article to be “speciality” dependent. Again, working around academic pathologists perhaps gives me a very different view of what goes on in the “real” world.

Yeah, I think that Pathology is more lenient with their hours…I think it also depends on where you actually practice, how much debt you have, etc…but most physicians do work tons of hours though. Many female physicians are opting for PT which is still long hours but it gives them more time with their families. Medicine is going to have to adapt to this because as more and more females enter this profession changes will have to made to accomodate for PT folks.

For anyone who had trouble, this is the correct URL.





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(Natalie: ) If you look in the Cleveland phone book, there are more malpractice lawyers than physicians. There are million dollar settlements where the patient sees about $12,000 and the lawyer gets the rest.







And one of them just might be Vice-President-elect of the United States by tomorrow morning.





If so, it won’t be through any action of mine.

Sheesh. The way you people talk, why would anyone want to become a doctor?
I’ve spoken with plenty of doctors in real life too, and virtually none of them have been 1/10 as negative as the martyr contingent one finds online.
I’m starting to think that some of you just want to minimize your future competition.

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Medicine is going to have to adapt to this because as more and more females enter this profession changes will have to made to accomodate for PT folks.


I agree, but for some specialities like surgery, I there’s but so much “accommadating” that can be done if the surgeon is to be any good. I really hate to say this but some areas of medicine just don’t make sense for women to pursue if they also plan to have a good, strong family life. Now if they marry “Mr.Mom”, then that’s different but I don’t know too many male egos that would be happy with that.
The medical profession and men are just too slow to change which I realized many years ago and promptly changed from wanting to be a surgeon myself.

Huh? we are not being negative just telling you like it is. I am by no means trying to discourage anyone from pursuing this path as I myself was not taken off the medicine track…but to think or assume that medicine is like any other job albeit long hours is just not real. Again, it all depends on where you end up at…you cannot compare well established physicians practices (that may be some of the doctors that you are speaking with) to the realities that awaits the younger generation of physicians. I am by no means making any of this up and/or trying to be some martyr. I am giving you what everyone I speak with tells me as well as what I am seeing. Most academic centers are following the 80 hour rule but remember that is 80 hrs in the hospital per week, the work continues from home (reading journals, studying, etc.) so by no means is your job “done” once you step out of the clinic. I do not know where you are getting your info but from all docs I talk to both at academic centers and community based centers they are working way in excess of 60 hours per week to keep their practices alive and be able to pay office staff.

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Huh? we are not being negative just telling you like it is. I am by no means trying to discourage anyone from pursuing this path as I myself was not taken off the medicine track…







I have made it NO secret that I GREATLY appreciate Efex’s perspective on med school, because it’s honest, sincere, and thought provoking.





BEFORE I read her posts and those of Texarose, I was questioning whether or not I could actually do this since I kept reading from others about how much of a breeze med school is and how they only study 5 minutes/day and make AOA.





Now not only do I now have a strong sense of what I, as a mother/wife, need to do to successfully navigate med school, I also know what additional classes I should take, and I have a REALISTIC idea about my own strengths and weaknesses. Most importanly, I’m more confident than ever that I CAN do this becasue I’m motivated and willing to take the advice of those in my EXACT SITUATION, who are successfully navigating the process. Finally, I find Efex’s posts HIGHLY ENcouraging and look forward to reading more.

Well I think it’s interesting how this thread has developed, since the thesis was a contrast between the old workaholic doctor and the new eight-to-fiver. From what people who are in the trenches are saying, it sounds like this “new” type is not really a trend, just an aberration that made this attending stop and think a little.
If the 80 hour rule saves lives and costs money, it sounds like a no-brainer; let’s spend the extra money to hire more residents to cover the hours. If someone refuses to work the full 80 hours I am not sure what kind of future they have. Will this screw them up, or will they just take their newly minted credentials and start a private practice or work at Kaiser or something?
Personally, it sounds exciting to be in residency. I’ve been deeply immersed in work before and it’s thrilling, albeit thoroughly exhausting and probably bad for one’s health. I want to be busy. If I could work 60-80 hours a week at something that saved lives (either through hands-on healthcare or research) versus 40 hours a week grinding out computer programs or managing a cube farm for the sole purpose of cashing that biweekly paycheck–well it’s a no-brainer for me which one is more compelling.
Regarding Natalie’s description of her surgical colleague, could it be said that this is unusual, or are all surgeons pretty much in that boat? Does he really have to work at three hospitals to make ends meet (i.e. pay for malpractice ins.)?

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Regarding Natalie’s description of her surgical colleague, could it be said that this is unusual, or are all surgeons pretty much in that boat? Does he really have to work at three hospitals to make ends meet (i.e. pay for malpractice ins.)?


Hi there,
It is very typical for newly minted surgeons to have to work upwards 120 hours to pay malpractice and expenses plus make a living. The reimbursements are going DOWN folks not up.
With decreasing reimbursements, increasing malpractice premiums why would anyone go into surgery? Because it is an awesome specialty and you love to do it. It is never, I repeat NEVER, going to be a lifestyle specialty but that is not why I or my colleagues choose to do this. We chose this specialty because we love it.
The lifestyle specialties have exploded in terms of competitiveness. Derm and optho have always been extremely competitive with very limited numbers of slots available. Anesthesia and path moved into the more competitive slots with very few slots available this year after the match. Ortho, ENT and neurosurgery have always been very, very competitive. Malpractice premiums for these specialties are extremely expensive, more so than general surgery.
The truth of the matter is that most pre-meds can’t see beyond medical school or residency but most people graduating today will never see even the income that I will see as a medical graduate two years ago. It just will not be there under the present system and I don’t see any changes on the horizen. Some states are downright dismal with Ohio, West Virginia and Wyoming among the worse.
Tort reform is very difficult for the general public to understand with changes coming very slowly as most lawmakers are lawyers(John Edwards notwithstanding). Along with tort reform, there are the issues of physician reimbursements and extremely rapidly rising malpractice insurance premiums for all specialties.
Natalie

What I’d like to know is how did we get to this point? When I asked a friend who’s a lawyer about this she said it was because physicians are too quick to “circle the wagons” when a medical mistake is made, forcing lawyers to go to extremes to see “justice” be done. My response, albeit extreme, was that if enough people start dying because Physicians can’t afford malpractice premiums needed to practice in certain areas, tort reform will get passed expeditiously.
Ironically, I recently had a major medical procedure, and when I read my physicians report, it read like a premptive “defense” in case the outcome wasn’t a good one for me (it was). What a shame physicians have to include “legalese” in their physician notes.

ttraub I asked the same question you ask regarding just hiring more residents to a consultant here at Mayo yesterday…and the bottom line is that you cannot just get up and get more residents. Maybe Dr. Belle can give us more insight into why…I am sure that there is some cap on how many residents can be hired per academic center. I was with a general surgeon all afternoon yesterday and one of the residents came in and she looked very very tired…again the same comments were made regarding how this 80hr/week just is not the best option for GS. You learn by DOING and this only will happen by the doing the same procedure numerous times for you to be competent. We have to think here folks, if I need surgery I hope to get someone that trained ENOUGH to be competent…different residencies require different types of training. Although yes, as your sleep time goes down more mistakes are made that is why there is a TEAM of folks taking care of patients and hopefully someone will be alert and notice some mistakes. But many more errors in surgical procedures may increase if GS residents are not trained properly just food for though. It may just be picking the lesser of two evils.

I admit to being facetious with the comment about discouraging future competition, but I do sometimes think that those here who urge such, shall we say, caution might be exaggerating as a kind of mental device to help themselves through the process. I.e., repeating “medicine is so hard and so thankless and such a quixotic struggle that mere mortals aren’t cut out for it and only those who love it more than life itself have even a remote chance of being content in it” is kind of a way to convince themselves that they have what it takes, maybe an especially felt need since so many are approaching or in middle age and don’t quite have the youthful energy they used to.
I still have to wonder about what’s being said about physician income and expenses, though, for 2 reasons: 1) Why is is that every source you can find shows the vast majority of doctors still making 6 figures, with even FM and peds making $125K on average (and that’s personal net income, not gross receipts)? Where do people like the guy who had to see 25 patients a day just to break even fit in to those statistics? 2) I have to believe that something WILL be done before it gets to the point where physicians literally have to worry about putting food on the table. Face it, if a certain profession requires 4 years of post-college education, plus 3-6 years of relatively low-pay, high-stress, long-hours training, at the end of which you have to continue working 12 hour days and struggle to feed your family, people are just not going to go into that profession. Governmental funding of med school so that we don’t have loans in exchange for increased governmental control of medicine (not my favorite solution), labor unions for doctors… something’s gotta happen. I can’t see our society letting medicine totally collapse.
Not trying to be snarky here; I certainly don’t think I know better than someone who already has their MD or has at least gotten into med school already. I’m honestly seeking information and still struggling to make up my mind about medicine. I just get frustrated since the main reason I’m still not totally decided is the vast difference between what the docs I talk to in real life say and what those online say.

I do not think that any of us have stated that this is a thankless profession. Those of us stating the difficulties (talking for myself here) know that I will make it through albeit a lot of work. No matter what we say until you get there you probably will not believe us. Just like I kept rolling my eyes and thinking comeon how hard can it be…It is the most time consuming and difficult thing (medical school) that I have ever done and I have done a lot of stuff to include combat time. So I am being brutally honest here and this is true for “most” medical students. We work a lot and maybe just still only “pass” which is good but the time you spend is unreal. This only gets worse during residency again the 80hr/week is a lot of time at the clinic and then the day is not over there are exams to study for and other things that you have to keep up with. I think that what you hear from established physicians that have been in practice for many many years is just not the current reality. Making 120K is a lot but you have a LOT of expenses from malpractice in the six figures in many places, to office staff, to rent, etc…so yeah although physicians DO make money they are not rolling in it…also think loans and the time it takes you to even get established…

To be fair the surgeon I constantly bombard with questions says, "Sure you’ll clear $200k/year but you will be working very hard. You can work 18 hour days as a ditch digger or you can work 18 hour days in the OR. Work is work. I just don’t believe I’d get the level of satisfaction in anything except surgery"
I’m not saying you will barely make ends meet. The doctor I was referring to did not want to pack up and move to parts of the country where he wouldn’t have to see so many patients. I don’t think alot of times the problem is finding work but working where you would for what you would like. For many it’s taking into account what you would need to provide for your family. Yes even the brokest physician is clearing 6 figures but what does that mean now a days. With a $2k in mortgage, $2k in loans, not to include any childcare, food, utilities, spouse loans, car notes, insurance (car, malpractise…), braces…It amounts to quite a hefty load. Thus the count the cost. This proposition of medicine for the non-trad is huge because money does play a factor. Before med school, during residency and then in practise. You have to do the math, see where you stand, decide either way and then feel confident you made the best choice for you. I have 4 friends who are now attorneys who were pre-med non-trads. They counted the cost and just said forget it. Forget MCAT, forget med school, forget residency, forget it all. Three were research techs and because of their research experience are making outstanding money with 100+ hours a week.
Unfortunately this discussion seems to have come down to money deciding how or where one will practise but it is a reality of the business of medicine. Where we all state we want to help people we also don’t want to starve doing so. There isn’t that true altruistic spirit because of Maslow’s hierarchy of needs. I’m not passing judgement on anyone. If the kind of medicine you want to practise does not lend itself to being some kind of materialistic martyr then that’s life. While I would love to give back to my community the reality is that unless I do so in a volunteer status it ain’t going to happen. Underrepresented communities just can’t afford many doctors because of the price of the loans. Perhaps better said many physicians can’t afford to go to the underrepresented communities because of the issues we’ve brought up here. There are many physicians who have chosen a specialty primarily because of money vs lifestyle. There are others who say the heck with it I’m doing what I love and everything will work itself out. I think this is a good approach because in the end the patients will sense this and hear it in your actions.
The other thing is those posting here are in the hunt. Whether of their prereqs, graduation from med school, residency, fellowship…and the hunt is exhilirating but at the same time dark and brutal. What I see and hear is soon to be physicians and residents giving us an “in the trenches” report. The established physicians have reached the other side and you sometimes quickly forget the trenchwork…sometimes you just don’t remember because of Q3 call. The surgeon I continue to refer can not recall his chief year as a surgeon. It’s all a blur. He has types of flashbacks like some kind of post traumatic stress.
Sheeeesh…reading my own post is depressing me. Let’s just say that take everything, including my post, with a grain of salt and start to get a wide sample of physicians to speak to. In the end the decision is yours. No one knows you better than you.
I guess the biggest question is which physician will you be…old or new?

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Sheesh. The way you people talk, why would anyone want to become a doctor?
I’ve spoken with plenty of doctors in real life too, and virtually none of them have been 1/10 as negative as the martyr contingent one finds online.
I’m starting to think that some of you just want to minimize your future competition.



I agree totally. I think everyone knows this is not your traditional 9-5 job.