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Reform in House Staff Working Hours and Clinical Supervision

American Journal of Medicine Editor Joseph Alpert

Joseph S. Alpert, MD, AJM Editor-in-Chief

William H. Frishman, M.D.

 

When we were medical interns (WHF and JSA), training in 1969, the weekday work schedule on the ward services was 36 hours on and 12 hours off. Every other weekend, there was a shift from Saturday morning to late Monday afternoon, 56 straight hours. We were off 1 Sunday every 2 weeks. There were only 3 patient handoffs a week, and we knew all the patients, including those of our covering co-interns as if they were members of our own families. In-hospital on-call supervision was provided by senior post graduate year-3 (PGY-3) or chief post graduate year-4 (PGY-4) residents. In public hospitals, attending physicians were rarely in the hospital during evenings and nights. During the on-call periods, we also had the responsibility of performing electrocardiograms, drawing blood, starting intravenous infusions, and performing simple laboratory tests, which included urinalyses, complete blood counts with differentials, and preparing Gram stains and acid-fast stains. We had to examine the body fluids, obtained from what were then intern procedures such as lumbar punctures, paracenteses, thoracenteses, and arthrocenteses. Fortunately, we often had third- and fourth-year medical students to help us with our ward work, but we also had to find time to teach them.

The work was both demanding and exhausting, and our house staff teaching conferences were often used as a time to take a nap. There was little sympathy from our teaching attendings who had gone through the same training process, and if you felt depressed and overwhelmed you were told by them ‘maybe medicine is not for you.’ Ultimately, we found it was better not to complain, because it was considered a sign of weakness and sometimes a reason for job termination. There were no wellness programs for interns at that time and no concept of burnout. Interns survived the training process by supporting each other, watching each other’s backs, similar to what combat soldiers go through in order to survive in battle. Based on our house staff experiences, we were well-prepared for our military tours in the Army (WHF) and Navy (JSA) medical corps during the Vietnam War.

Were the late 1960s the golden years of medical training? We were told that our struggles were a hazing one needed to go through to be a good physician. Clearly this was a myth. After all, how effective could an exhausted and depressed physician be in providing optimal medical care? It was remarkable that our patients did not suffer, and often, in reality, they benefited from the around-the-clock coverage we provided. Often our patients would tell us ‘you look exhausted doctor.” Our appearance of exhaustion was not very reassuring to them.

The house staff unions that were formed in the late 1960s and early 1970s provided better salaries and benefits but no changes in the work schedule. House staff wellness and work schedules were never an issue in the 3 house staff strikes that went on in New York City during the 1970s and 1980s.

The great changes took place in 1989, the first real reform in postgraduate training since the days of Dr William Osler and Dr William Halstead, when the old training system was created;1, 2 the training of medical students had been reformed following the release of the Flexner Report in 1910.3 At the time, I (WHF), was chief of medicine at the Hospital of the Albert Einstein College of Medicine in the Bronx, New York, which was part of Montefiore Medical Center. At Einstein, we were at the epicenter of the impending reform and the first to see it coming.1 Dr Bertrand Bell, the catalyst for the changes, was a member of our faculty. Dr Bell worked in Albany, the New York State capital, during an academic sabbatical from Einstein, with the state commissioner of health, Dr David Axelrod. Both had gone through the old training system. Dr Bell was trained as a gastroenterologist and was a bit of a maverick and an iconoclast who was dedicated to providing care for the underserved population of the Bronx. At Einstein, he had become the director of the Medical Clinic, where all of the house staff worked, and he would also become one of the founders of the newly emerging field of emergency medicine.

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-William H. Frishman, MD, MACP, Joseph S. Alpert, MD

This article originally appeared in the December issue of The American Journal of Medicine.

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