When I was an Intern
I am finishing up this issue of On the Same Page on the afternoon of July 2, at about 6 p.m. At 6 p.m. on July 2, 1979, I was finishing up my first 36-hour rotation as a new intern at The Johns Hopkins Hospital. Afterward, I vividly remember arriving at my apartment completely exhausted, and yet exhilarated. Could I make it through four years of this medical equivalent of boot camp? Did I want to? Well, at some point during that first rotation as an intern everything seemed to click. I was hooked on clinical medicine.
Now, July rolls around again. Although the calendar tells us that summer has begun, the beginning of a new residency year feels more like spring in the world of health-care training — a time of renewal and a time of new growth. A fresh cadre of residents and fellows commence training in their chosen specialty or subspecialty.
Although internship has become more “civilized” in recent years, and appropriately so, the process of transforming fledgling, newly minted M.D.s into skilled, confident physicians remains, at its core, essentially the same. There is some level of tension in this process, however, because of a peculiar intergenerational phenomenon among physicians: each generation believes their successors have it too easy. “When I was an intern…,” the seasoned attending physician would say, beginning a rant about how tough things were. “Don’t start with ancient history again!” the beleaguered intern would think, outwardly showing a faint, polite smile.
Across time, the structure of residency education has, indeed, changed. There was a time when being a resident meant literally living in the hospital. This gave way to every-other-night call, every-third-night call, etc., and finally (horror of horrors to those who believe that continuity-of-care experiences for residents can only occur in a traditional on-call system) a contortion called “night float.” Grafted onto this process of gradual change was a watershed event. In 1984, when a patient at New York Hospital died in the care of a resident who had been on call the previous night, the issue of resident work hours caught the public eye. In 1989, after a publicly aired ordeal that was as much political as medical, New York State set work rules for house staff — no more than 80 hours on site per week, and no patient care the day after an overnight shift.
New York’s approach led to national changes in resident work hours. In July, 2003, the Accreditation Council for Graduate Medical Education (ACGME) limited the number of work-hours to 80 hours weekly, overnight call frequency to no more than one overnight every third day, a 30-hour maximum straight shift, and 10 hours off between shifts. While these limits were voluntary, adherence was essentially mandated for the purposes of accreditation.
A causal link between sleep deprivation and medical errors was reported in an oft-cited study by Christopher Landrigan and his collaborators, which appeared in The New England Journal of Medicine on Oct. 28, 2004 (351:1838-48). These investigators conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working “every third night” call (traditional schedule) compared with a schedule that eliminated extended work shifts and reduced the number of hours worked per week (intervention schedule). During a total of 2,203 patient-days involving 634 admissions, interns made 36 percent more serious medical errors during the traditional schedule than during the intervention schedule, including 57 percent more non-intercepted serious errors. Following this landmark study, a large literature has now accumulated regarding many aspects of the association between sleep deprivation and medical errors.
Of course, the solution to one problem sometimes creates others. Fewer duty hours for residents has likely reduced errors due to sleep deprivation, but it has also created more frequent hand-offs of patients from one resident to the next, which increases errors. Moreover, it doesn’t always follow that if reducing continuous duty hours a certain amount is a good thing, reducing it a lot more is better. In 2011, stricter national regulations from ACGME, reducing the continuous-duty hours of first-year residents from 30 to 16, were put into place. The theory was that limiting residents’ work hours even more would lead to more sleep and fewer medical errors. But, according to a study by Sanjay Desai in the March 25, 2013 issue of JAMA Internal Medicine, these new rules have had unintended consequences.
Desai and his colleagues compared three different work schedules in the months leading up to the 2011 change in a randomized prospective trial at Hopkins. For three months, groups of medical interns were assigned randomly to either a 2003-compliant model of being on call every fourth night (with a 30-hour duty limit), or to one of two 2011-compliant models: being on call every fifth night but working only 16 hours straight, or a night float schedule, which essentially had interns working a regular week on the night shift not exceeding 16 hours. The results showed that the 16-hour duty limit failed to increase the amount of sleep each intern got per week, but increased the number of potentially dangerous handoffs, reduced the quality of care as perceived by staff nurses (so much so that the night-float model was discontinued), and impaired formal rounding and other educational opportunities. For example, before the limits, interns did all patient admissions and generally spent the next 24 hours following those they admitted through the course of their disease. Under the new rules, there were times in the day when interns could not admit the patients nor see them through initial assessments.
In the same March 2013 issue of JAMA Internal Medicine, Srinjan San and his collaborators reported similar findings using a different methodology. These investigators conducted a longitudinal cohort study of 2,323 medical interns in 51 residency programs at 14 GME institutions, comparing interns serving before (2009 and 2010) and interns serving after (2011) the implementation of the new duty hour requirements. Duty hours decreased from an average of 67.0 hours per week before the new rules to 64.3 hours per week after the new rules were instituted. Despite the decrease in duty hours, there were no significant changes in hours slept by interns, or in their depressive symptoms or well-being scores. Under the new duty hour rules, however, the percentage of interns who reported concern about making a serious medical error increased significantly from 19.9% to 23.3%. The authors conclude: “Although interns report working fewer hours under the new duty hour restrictions, this decrease has not been accompanied by an increase in hours of sleep or an improvement in depressive symptoms or well-being but has been accompanied by an unanticipated increase in self-reported medical errors.”
The debate over duty hours will continue, hopefully informed by data. Meanwhile, our new interns will be living, in real time, their own “When I was an intern” experiences, to be handed down to their successors.
I will close with the story of “when I was an intern” as told to a group of entering ob-gyn interns a few years ago by a mentor of mine, Howard W. Jones Jr., M.D. See The New York Times article on Dr. Jones.
Dr. Jones was a resident at The Johns Hopkins Hospital in the late 1930s. He received no pay, but didn’t need any: He lived full-time in the hospital. He received five pairs of white pants, five white shirts and five white coats, all of which were laundered on his behalf. (These uniforms were replaced yearly.) All of his meals were taken in the “Doctors Dining Room,” which was adjacent to the hospital cafeteria. The food was the same, but it was served on tables set up with linens and place settings. A small bedroom was provided in the Hopkins dome. Food, shelter and clothing … all that he needed was provided.
Dr. Jones spoke of the indelible significance of going to the hospital’s tailor to have his name hand-stitched on his white coat. He remembered the names of his first three patients, and cared for them not only for the several days of that hospitalization, but also for many subsequent visits over succeeding years. He knew them well, and told their story not only from a medical standpoint, but also in terms of their family, and the community and social culture in which they lived. Dr. Jones also remembered the names of the nurses in the operating rooms and wards with whom he worked every day, and commented extensively on how they served as role models for the level of skill, attentiveness and caring that they gave to each and every patient. Finally, he talked about colleagueship — the bonds created by this experience that lasted for decades to come.
Few residents married during residency in those days. (Occasionally, this was allowed by special consent of the Chair.) Georgeanna Seegar was a Hopkins medical student whom Dr. Jones met in July of his intern year. He asked her if she would go out on a date with him during his first night off, which would be in late September. She agreed. As Dr. Jones tells it, the date consisted of meeting at the hospital where they looked at pathology slides together. Georgeanna Seegar went on to marry Howard Jones and become a prominent gynecologic endocrinologist in her own right. (Dr. Georgeanna’s first discovery, in the 1930s, was that the hormone of pregnancy — now recognized as hCG — was produced primarily in the placenta, not the pituitary gland.) Together, after leaving Hopkins in 1979 because of age-related mandatory retirement, they learned in vitro fertilization from their former fellow, Dr. Robert Edwards, in England. In 1981, they began the first successful IVF program in the United States at Eastern Virginia Medical School. They continued to be active in what became, over the next decade, the most prominent IVF program nationally. Dr. Georgeanna Seegar Jones died in March 2005 at age 92. Dr. Howard Jones is now 102 and continuing to contribute to academic life.
Next week, we will be hearing some stories about “when I was an intern” from our faculty. It should be interesting!
David S. Guzick, M.D., Ph.D.
Senior Vice President, Health Affairs
President, UF Health