Understanding the Modern Challenges of Student Doctors

An Evolving Educational Model

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By Cyndi Laurenti

laurenticy@gmail.com

Medical education could be driving potential doctors away and damaging those who do go on to practice with long hours, high debt, inconsistent training, and lack of emotional support. Research indicates the current structure of residency programs produces resident physicians who are stressed, sleep-deprived, and prone to medical errors.

Medical Residents

Medical school graduates who’ve begun their on-the-job training are called residents varying in length from three to seven years, depending on the specializations doctors pursue. Most programs utilize experienced physicians called preceptors to teach the new doctors how to practice their particular branches of medicine. Another common practice is to pair second- or third-year residents with one or more first-year residents, so the senior students take on some of the teaching and supervision roles.

Duties

Residents admit patients to the hospital, obtain medical histories, perform examinations, and administer treatments or do procedures under the guidance of the senior resident or preceptor.

The hours in a residency program are long. Despite recommendations from the Institutes of Medicine intended to decrease long shifts and work hours, 80-hour weeks are common in residency programs and 30-hour shifts with five-hour sleep periods are the norm. Moreover, those 80-hour work weeks represent the average over a four-week period, so a resident might actually work considerably longer in a single week.

Work Shifts

Rotating shifts, in which residents work at different times of the day or night, are also common. Sleep deprivation is the norm: a 2004 survey of over 3,000 residents reported 66 percent slept less than six hours a night, and 20 percent slept less than five. Of even more concern, those who slept less than five hours a night reported they had used alcohol, resorted to stimulants to stay awake, had serious accidents or injuries, had conflicts with other professional staff, or made serious medical errors.

Financial Stress

Many residents also face financial or family stressors as well. Debt is common in medical school: the New England Journal of Medicine reports one fourth of graduating residents have debt exceeding $200,000. Some residents use their limited free time to moonlight for additional income as the average medical resident salary is about $45,000 per year.

Age

Medical residents are often in their late twenties or early thirties, a time when many people look to starting families. The lack of income may drive them to work extra hours in an already crowded schedule, which prevents them from spending time with children or a spouse, if indeed they manage to have either. Research from as far back as 1986 indicated over 40 percent of medical residents experience problems with their spouses during residency. Respondents often feel the working conditions of residency contribute to family problems, which in turn affect their hospital work as a result. On a positive note, researchers have found stress can be moderated by family relationships and social contact, and recommended social support systems be fostered in residency programs.

Stress

Emotional stress related to patient care is another aspect of the issues with residency. Over 70 percent of residents in one study reported hospital activities such as cardiopulmonary resuscitation were extremely stressful and the lack of a debriefing session afterward increased the impact of that stress, particularly when the resident felt the resuscitation was inappropriate.

Recipe for Disaster?

The combination of stress and sleep deprivation is a recipe for disaster. A study at HarvardUniversityfound residents who worked extended shifts or long hours were involved in 300 percent more fatal errors than when they did not work excessive hours. These same physicians reported they were likely to fall asleep during surgery, patient examinations, hospital rounds or lectures, and that their medical errors induced guilt, anger, humiliation, and decreased compassion for the patients they treated.

To add to these stresses, as recently as October 2011 almost half of graduate physicians in one survey reported they had been harassed, intimidated or discriminated against while residents. These behaviors took the form of verbal abuse and being assigned extra work as punishment. The sources of inappropriate behavior were primarily specialty physicians, but specialty residents, hospital nurses, and patients also participated in the harassment.

The Changing Paradigm

Some residency programs have made changes to improve the quality of life for residents. These include strategies such as decreasing patient load, senior residents supervising a single resident instead of two or more, and decreasing hand-offs, the transfer of patients from one group of residents to another. Other recommendations include debriefing sessions for stressful situations such as cardiopulmonary resuscitation, ethics committees to which residents can take complicated problems, and increased emotional support.

I.O.M

Other possible strategies include a decreased shift length, or simply adherence to the Institutes of Medicine’s guidelines for residency training programs. Social networks for residents’ spouses and families would provide a forum to air concerns and obtain emotional support from those in similar circumstances.

Additional efforts to relieve medical student debt would also make a considerable positive impact. A program currently exists in theUnited Statesfor physicians to obtain loan forgiveness: the National Health Service Corps pays off medical student debt if the physician practices full-time at a NHSC-approved site, usually a federally-qualified health center, rural or Indian Health service clinics, or prison. If a physician serves full-time for six or more years, the entire debt may be repaid by the NHSC.

Assessment

Most residency programs in other parts of the world are similar to those in theUnited States, although there may be different laws that affect work hours or salaries. There is clear evidence that overstressed and sleep-deprived residents are more likely to make serious or even fatal medical errors and lose their sense of compassion for patients. The current residency system is expensive, emotionally stressful, and puts the lives of patients at risk. America (and likely other nations as well) would benefit from making even more changes in residency programs to provide adequate time for sleep, family or social interaction, and emotional support for fledgling doctors.

About the Author

While she figures out her next career move, Cyndi Laurenti works as an online writer and editor. Her primary interests are education, technology, and how to combine them. She enjoys the trees and beaches of thePacific Northwest, and looking things up on other people’s iPhones.

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4 Responses

  1. Rethinking Medical Education

    Last spring, according to Professor Richard R. Fuchs, in his elegant commencement address to the Harvard Medical School, Dr. Atul Gawande appealed for a dramatic change in the organization and delivery of medical care.

    His reason, “medicine’s complexity has exceeded our individual capabilities as doctors.”

    http://thehealthcareblog.com/blog/2011/11/11/rethinking-medical-education/#more-34251

    Dr. David Edward Marcinko MBA
    http://www.BusinessofMedicalPractice.com

    Like

  2. Cyndi and Dr. Marcinko-

    It is no wonder that there is a feeling of delayed gratification by the physician after the rigors of college, medical school, residency, and fellowship!

    This can unfortunately lead some physicians to live lavishly once they are practicing. After all, how many professionals go from paltry minimum wage earnings to nice six-digit salaries like physicians do? The doctor may feel that it is time to buy the big house, luxury car and finally live after years of sacrifice.

    I have seen in my own practice however that when a physician does this it can inflict more harm as it causes a physician to delay or reduce savings and can deny possible future options.

    A doctor that is living within his or her means will have enough money in the future to reduce their practice hours or take time off or retire early. I believe that it is important to help the physician understand that even though they have paid a great sacrifice in receiving their training, the goal is to plan a secure retirement.

    Indeed there is a dramatic need for change in the organization and delivery of health care and the current system endured by student doctors seems inequitable when considering the high personal costs they must make.

    David K. Luke, MIM
    Financial Advisor
    (Fee Only)

    Like

  3. Another Way Student Loans Are Like Mortgages – Subpar Servicing

    The companies handling private student loans — much like those handling mortgages — sometimes add to the frustration and even the debt load of struggling borrowers.

    http://www.propublica.org/article/another-way-student-loans-are-like-mortgages-subpar-servicing

    Ann Miller RN MHA

    Like

  4. Lenders to students: Now that you’re out, we want our money back

    Did you now that seven in 10 seniors graduate with debt, owing about $30,100 per borrower, according to the most recent data from the Institute for College Access & Success.

    http://www.msn.com/en-us/money/careersandeducation/lenders-to-students-now-that-youre-out-we-want-our-money-back/ar-BBBMIZU?li=BBnbfcN

    BriAnna

    Like

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