Residents: The perils and promise of educating young doctors (Scribner)
Residents: The Perils and Promise of Educating Young Doctors
“Duncan… captures dramatically what goes wrong, not only during medical training but also in much of the care provided by American hospitals today… I hope someone is listening.” – Washington Post Book World
“Duncan has written a chilling exposé that should be read at all hospitals and medical schools.” – Publisher’s Weekly
Residents was the subject of "The Intern," a 2-part ABC Nightline Documentary; aired September 16-17, 1996, David Ewing Duncan, Producer and Correspondent, Narrated by Ted Koppel
This expose of the inner workings of America's medical training programs is both a stirring cry for reform of a health care system that endangers all of our lives and a collection of tense and terrifying stories of real life-or-death drama. – from the book jacket
This book began as an article:
“Is this any way to train a doctor?” Harper’s, April, 1993
An excerpt from the article:
“Even as President Clinton, Congress, physicians, and insurance companies grapple with the cost and availability of health care, another, more basic medical crisis looms--the nation's teaching hospitals are dangerously overworking and exploiting their medical residents. This stressful, painful process is, in turn, creating young doctors who often fail to develop a broad understanding of what it means to be healers of people. Trained in a harsh and unforgiving environment, too many go on to become harsh and unforgiving professionals themselves. Meanwhile, their lack of sleep and proper supervision continues to endanger patients at even the best teaching hospitals.
“When my wife began her medical residency at a Baltimore hospital two and a half years ago, we braced ourselves for what we knew would be an ordeal--three years of eighty- to one-hundred-hour workweeks, thirty-six-hour shifts every third or fourth night, and a salary of about $4.30 an hour. In the weeks leading up to her starting date, we talked frequently about our precarious family finances, child care, and the impact of my wife's schedule on our kids. We discussed how residencies had brutalized people we knew, breaking up two marriages involving close friends, driving two others to contemplate suicide, and leading yet another to become addicted to a narcotic that he said got him through long nights on call. We'd heard stories about minor errors and near misses with patients, all blamed on fatigue, fear, and lack of proper training--a surgical intern falling asleep on her feet in the operating room, a frazzled resident forgetting to order morphine for a patient in pain, a breathing tube inserted into the wrong person's throat.
“Yet my wife seemed better prepared than most starting residents. At thirty-two, she was not only the second-oldest in her class, but a symbol of a new era in medicine--a time when a married female with children is no longer blocked from becoming a physician. She also had reason to believe she could handle the stress of the residency, having worked for half a decade in another pressure-cooker profession, investment banking, logging seventy- to eighty-hour weeks on Wall Street. "I expect it to be far worse than the Street," she told me then, "but in medicine, I'll be doing the work because I love it, not because I have to."
“She began her residency in the summer of 1990, and her decline began soon thereafter. Working a series of monthlong rotations, she spent July on the infants ward, trying to cope with ninety-hour weeks that included two or three overnight shifts. In August, she moved to the emergency room, where she worked a nonsensical schedule that utterly ignored sleep patterns and body rhythms, subjecting her to night shifts, afternoon shifts, and morning shifts, all in the same week.
“That fall she moved again, this time to the neonatal intensive-care unit (NICU), one of the toughest rotations in the hospital. She came home after her first call night with a face so swollen from fatigue and worry that I hardly recognized her. For most of the night, she said, she had been the sole physician in charge of thirty-five pre-term babies attached to intravenous tubes, ventilators, and monitors. Half were under thirty weeks old. There were AIDS babies, crack babies, babies born with malformed lungs and hearts, and babies being slowly poisoned by bacterial (septic) infections. "Around two, I had two babies crash on me," she said bitterly, taking a deep breath as she recalled the long night. "One was septic, and the other was turning blue. I had no idea what to do. They gave me no training, no explanations about how to run the ventilators or how to mix and adjust the [intravenous] fluids. If the nurses hadn't been really good, we would have lost one."
“’But where were the attendings?’ I asked, meaning her supervising physicians.
"’Home.’ She explained that a third-year resident was theoretically on call to help her but had been gone most of the night, assigned to cover labor and delivery as well as the NICU.
"’You're telling me you were alone running the entire NICU--A first-year resident?’
"’It's their version of |hell night,'" she said icily, "the first night on call on a new rotation, when they leave us alone, basically to sink or swim…”
Selected Reviews and Comments
“Duncan spent four years observing, and sometimes living among, residents in more than a dozen U.S. hospitals. He saw dosages mixed up, drugs given that shouldn't have been, procedures put off for days because a resident forgot or was too busy, and horrific, life-endangering incidents that might never have occurred with proper supervision. He met overworked, pushed-to-the-edge residents everywhere, many suffering severe sleep deprivation, overwhelmed by a system that uses errors as a training tool and purposely places young physicians with minimal training in complex, intense situations. All those he interviewed spent at least 20% of their time-and often 70%-at such basic tasks as finding clean sheets and starting intravenous drips without backup support. Suicides and suicide attempts were shockingly frequent among residents. Duncan (Hernando de Soto) has written a chilling expose that should be read at all hospitals and medical schools. His proposed reforms, including protected sleep time, hands-on teaching, tighter supervision and caps on the number of hospital admissions, seem eminently sensible.” – Publisher’s Weekly
"David Duncan has taken a scalpel to the body of medical denial, probing the wrongs and suggesting a course of healing. A brave book." – Samuel Shem, M.D., author of the bestselling House of God
"No-punches-pulled scrutiny of the flawed system that produces our nation’s doctors… An up-close and sobering picture of medical education’s imperfections." – Kirkus Reviews
"Duncan has gathered a riveting collection of facts and stories and fairly presented all sides of this vital and complex issue. Duncan’s presentation of the powerful tension between differing pedagogic ideals is highly recommended." – Library Journal