Addressing Residency Young Doctors Size Up Their Learning Experience

Kirstin Wilson took a few minutes to find what she considered the right words to capture the ordeal known as medical residency.
“I guess the best way to describe it would be to say that it prepares you for the worst,” said Wilson, 30, who completed a four-year residency in obstetrics and gynecology at Baystate Medical Center earlier this month. That’s a diplomatic way of saying that residency throws more at an individual than he or she could ever expect to see in actual practice, she told The Healthcare News.

And for Wilson, that meant looking after 15 women who were in various stages of labor of the same time in Baystate’s maternity ward. “So I’m conditioned,” said Wilson, whose husband, Andrew Williams, is wrapping up the second year of a three-year residency in internal medicine at Baystate. “I know that when things get bad when I’m on my own, I’ll be able to handle them.”

Larry Volz, who recently completed a surgical residency at Baystate, chose similar words. “I’m properly versed,” he said of his five-year tour of duty, one that will be followed by his four-year commitment to the U.S. Air Force as a surgeon at Offutt Air Force Base in Omaha. “I’ve been trained well here … I’ve been exposed to everything, and because of that I feel I can handle anything.”

And this, in a nutshell, is what residency, that rugged period of learning and doing between medical school and formal practice, is all about — making people ready. Just how residents are made ready is becoming a subject of debate and increasing controversy, however.

Some contend that residents are being asked to do too much, work too many hours, and endure lengthy shifts that raise questions about whether they are too fatigued to treat patients safely. In response, the Accreditation Council for Graduate Medical Education announced the first national limits on the work hours of residents, establishing an 80-hour work week. The policy will take effect in 2003.

Residents we spoke with acknowledged that there were times when they were pushed to the limit — and often well beyond — but they considered this part of the price one must pay to be fully prepared for life after residency. Volz, for one, said he understands why there are calls to cut back the hours residents are required to work, but he said that if the workload is reduced, so too are the opportunities to learn.

The challenge, said Anne Weaver, who will complete a four-year double residency in pediatrics and internal medicine on June 30, is to strike the proper balance.
“You don’t want people wondering whether the doctor taking care of them is awake enough to properly treat them,” she explained. “At the same time, we’re here to learn, and how can you learn if you’re not doing things?”

The Healthcare News talked this month with several residents about finding that balance, and about the many other challenges of residency — from finding time to do anything other than their medical work to handling the daily stress that comes with the job.

All those we spoke with said they were happy to be putting this phase of their career in the rear-view mirror, but there are many elements of this unique experience that they’ll miss.

Taking the Pulse

Volz told The Healthcare News that his two young children referred to Baystate as “daddy’s house.”

That’s because he lived there, in both a figurative and sometimes literal sense. The hospital was never his mailing address, but he spent many nights and weekends there. Looking back, he said residency completely devoured five prime years of his life — those between ages 25 and 30 — leaving him little time for his children or anything else.

But there are absolutely no regrets, he said, because one knows going in that residency, and the entire eight- to 10-year educational commitment one must make to become a doctor, is an all-consuming proposition.

Indeed, those who enter residency know that they will be making huge sacrifices, said Wilson, who noted that having a husband who is also in residency brings both benefits and complications.

Between their two schedules they have little time to themselves, she explained, but because they’re both going through the experience together, there’s a heightened level of understanding.

“There are stretches where we don’t see each other for days at a time except when we pass each other in the halls,” she said. “There’s mutual understanding, but there’s also twice the stress.”

Dr. Paul Friedmann, senior vice president of Academic Affairs at Baystate, said residency is designed to give students the opportunity to take the knowledge they acquired in medical school and apply it in a working setting. It’s the final stop before individuals begin private practice, he explained, and therefore it must fully prepare people for what they face when they’re on their own.

Length of residency varies with the specialty, said Friedmann, but most are four- or five-year endeavors, and they can stretch to seven years or more in some specialty areas. Baystate, the area’s only teaching hospital, has about 250 residents at any given time, he said, all of them performing the same duties as a licensed doctor — Wilson has delivered or helped deliver some 500 babies in her time at Baystate — but always with a supervisor either watching or actually assisting.

Interest in specific specialties often varies from year to year, Friedmann said, depending what are considered the “hot” fields. There are a number of factors that go into that equation, he said, listing everything from the difficulty of the educational requirements to the state of the job market to the lifestyle afforded by that specialty.
And increasingly, lifestyle is becoming more prominent in the decision-making process, said Friedmann, adding that because of this, areas such as emergency medicine, radiology, and anesthesiology, all with more regimented schedules than many specialties, are becoming more popular – a positive trend, since all have seen recent shortages.

“The so-called lifestyle specialities are becoming increasingly popular,” he said. “In emergency medicine, for example, the working environment is on a shift basis — when you’re on, you’re on, and when you’re off, you’re off — and people like that.”

Medical school graduates arrive at a specific hospital via a matching process that has become a spring ritual across the country. Students prioritize their choices for assignment — based on factors ranging from geography to quality of programs to reputation of the teaching staff — and hospitals also rank the students seeking entry into specific areas of study. A computer ultimately matches candidates with hospitals.

Wilson and Williams, who met at Eastern Virginia Medical School, chose Baystate both for the quality of its programs and because Williams’ family lives in the area. Wilson arrived at Baystate two years before her husband, and she’ll leave one year before he does — she’s secured a job in Denver, which will add to their already complicated lifestyles.

When asked to describe their experiences, both said residency is grueling and quite stressful but, in the end, not much more than they expected. Wilson said her tour of duty has been complicated by illnesses that have struck two other residents in her department, which has added to her workload. Indeed, when Williams said residency often leaves one tired but not overwhelmed, Wilson laughed and said, “speak for yourself.”

Williams described his life as an internal medicine resident as a sprint, with long, hectic weeks followed by stretches that are far less so, and Wilson’s as more of a marathon, a longer race with the same grinding pace each month.

“I don’t want anyone to think that residency has been easy … I have months where I’m working 100 hours a week,” he said. “But I have months that are more like a sprint pace. I get through that month, and next month is a normal month and I can get back to my life.”

But even so-called “normal months” are grueling, with 60- to 70-hour work weeks and shifts that last from 7 one morning to 9:30 or 10 the next morning, with many nights on call.

Wilson said the illnesses of others in her department only added to what she called the typical stress of an OB/GYN residency. “That’s the stress that comes when you’re trying to learn, trying not to screw up, trying not to kill someone, and trying not to get yelled at,” she said. “Now add the stress of not having enough people to cover everything all the time.”

Body of Evidence

In the end, though, Wilson said residency has done what it was designed to do — prepare her for whatever private practice can possibly throw at her.
“As rough as it’s been, it’s been worth it,” she told The Healthcare News. “There are programs I could have been in that might have been much easier on me, but I can manage 15 people in labor at once, I’ve really learned how to multi-task.

“When I get into the private world, as hard as it is, when the normal complications happen I’ve developed a reflex to say, ‘we need to do this, we need to do this, and we need to do this.’ I’ve been conditioned,” she continued.

Williams, still with a year to go, feels he will be similarly prepared for life after Baystate. “No matter where I go, I know I’ll do well because of what I’ve been able to do here,” he said. “On the medicine side, the program is set up in a way so you can get as much out of it as you want to take. Everything is there to help you succeed, but ultimately what you get out of a residency is a function of what you put in.”

Weaver told The Healthcare News that, in a word, she feels ‘ready’ to open the private practice she will operate in Amherst with another doctor. The day after she graduates from residency, she’ll go to work at that facility, a scenario that prompts equal amounts of apprehension and anticipation, she said.

“It’s a nice feeling to be ready,” she said. “It gives you the confidence you need to move forward. I’m comfortable with my own skills.”

Medicine is a second, very different career for Weaver, who was a flutist and choir director in another life. When the harpist who formed the other half of a musical group she created moved away from the area, Weaver searched for something else to do with her life. While volunteering with Cooley Dickinson Hospital, she discovered that health care was her calling.

Her residency, which involves caring for both children and adults, has been challenging, in part because treating children is much different than treating grown adults, but also because of the work involved going back and forth between the two elements of the specialty. “It’s scary sometimes to flip back and forth,” she explained. “But that’s part of what makes this residency unique.”

Weaver said that having older children made the residency experience easier in terms of the demands on her time outside of her medical commitments, but the tour of duty was draining nonetheless.

“The hardest part is planning and scheduling things,” she said. “You’d love to tell someone that you’ll be available to do something on a certain day at a certain hour, but most of the time you can’t do that.”

Still, she said she did find time for things other than medicine, including music — she has directed her church choir and helped orchestrate a music night at the hospital featuring the talents of many of the residents — and that most residents are somehow able to do the same.

“People bike and hike and somehow do the things they like to do,” she said. “It is possible to have some kind of life.”

Still, the sacrifices are enormous, said Volz, who told The Healthcare News that he managed to see his children a few days a week during his rugged surgical residency. “I would be on call a few nights a week, and when I wasn’t on call I’d usually get home after they went to bed, so I didn’t see them much.”

A Cut Above

Volz, who hails from Los Angeles, calls himself a sports fan but ultimately uses mostly the past tense to describe his individual passions.

“I used to watch SportsCenter two hours a day,” he said, referring to the popular ESPN program. “I think I’ve watched it five times since I’ve been a resident.”
Keeping track of his beloved Lakers is only one of the casualties of residency, and a minor one at that, said Volz, who told The Healthcare News that he often learns of significant national and international events days after they happen because his schedule simply doesn’t allow him to read the newspaper or watch the news.
Such is life for a resident, especially one in surgery, where the hours are especially demanding because of both the workload and the limited number of people that can address it. When he first started his residency, Volz said 120-hour weeks, while rare, were part of the equation.

He remembers days when he was so tired that it would have been beneficial that he not work, but he expects such conditions in the so-called real world, and thus he believes residents should endure them as well.

That’s why he looks upon efforts to restrict surgical residents to 80 hours per week with a healthy dose of skepticism. In fact, he says he’s glad he was a resident when the 100-hour week was the norm.

“The focus is now on 80 hours, and because of that a lot of things have changed,” he said. “And some of those changes have been hard for the surgical community. Because there are only so many residents allowed and so much work to be done by that group, we had to take coverage away from some of the private attendants in the community, and that was a very difficult process for us.

“There was clearly too much work to be done by the staff we had in here,” he continued. “In order to cut the hours back, we had to tell some private attendants that they couldn’t get resident coverage anymore.”

Ultimately, this reduces the number of learning experiences a resident can have, he said, adding that residents who worked with some teachers for the first several years of their residency were not to continue working with them the past several months.

The 80-hour work week is a totally new thought process for the surgical community, said Volz, who said debate continues on what the long-term ramifications of shortening the schedules will be.

“No one knows how that’s going to impact surgical training,” he said. “The thought has always been that, by working a lot of hours, you see a lot of things during that time — you’re tired, but you’re getting a lot of experience. We don’t know if people will put in better hours because they’re more rested, or if the experience will be lost. Time will tell.”

Friedmann said the debate over the number of hours residents can work and the length of shifts has intensified in recent years, and many pieces of legislation have been filed to address the issue — without any hard scientific evidence to support the argument that an 80-hour week is in any way more beneficial.

“You have to remember what we’re trying to accomplish with graduate education,” he said. “This is a transformation process … we’re taking a physician out of medical school and showing them how to apply what they’ve learned. And there is no substitute for time and practice.”

Like Volz, Friedmann said that something will have to give if efforts to shorten residents’ schedules are ultimately successful, because the amount that needs to be learned remains constant. One possibility is lengthening the residency, perhaps by a year or more, to recover the time lost due to the shortened work weeks, he said.
“We’re not trying to overwork people,” Friedmann explained. “But it’s hard work, and it needs to be done 24 hours a day, seven days a week. Residents have to learn how to do it.”

Weaver said she understands both sides to the discussion on the number of hours and the length of the shifts residents are required to work. Residency shouldn’t ever be easy, she said, but there is a fine line between working people hard to properly train them and burning them out.

“People shouldn’t get so burned out or bitter that they lose their sense of compassion,” she explained. “You don’t want people saying, ‘I don’t want to see another patient; I just want to get out of here and get some sleep.’”

Another aspect of the discussion is that doctors, in addition to treating their patients, also promote good health, she said, and they should practice what they preach. “We tell people to eat right and to get enough sleep and to take care of their bodies,” she explained. “Here we are doing just the opposite.”

Resting Their Case

Whether they work 120 hours, 80, or even 60, it’s unlikely that residents will ever lead the kind of healthy lifestyle they urge their patients to practice.

The institution of residency requires people to put aside much of what most people would consider a regular life in the name of preparing themselves for the rigors of life when someone isn’t looking over their shoulder.

Kirstin Wilson calls it “preparing for the worst,” and because residents somehow manage to survive the experience, they are able to be at their best.