March 31, 2023
Dear Interested Readers,
There Are Big Problems In the Pipeline For New Doctors
It’s been a long time since “Match Day 1971,” and I don’t remember the scene as well as I remember the emotions. I was delighted to learn that I had “matched” at The Brigham where I had done my medicine rotation as a student, and I would not need to move my family to someplace like Philadelphia, Rochester, New York, or Chapel Hill, North Carolina. I remember being concerned about a friend who had not matched. Apparently, someone in the Dean’s office had placed him in a pretty good program in the Midwest that had not filled all of its slots. Some of my classmates shared my elation, others looked like they were dealing with disappointment.
Everyone was trying hard to be positive. We had all been through a series of similar moments as we had applied to colleges and medical schools. The “match” was probably not going to be the last dance, but it was an important moment because where you did your internship and residency would likely impact the quality of your fellowship program as you continued up the ladder of medical education toward your ultimate goal. One could also imagine it would impact where you finally took a job and built a life.
I have not paid much attention to “Match Day” once mine passed. Last Sunday, my wife returned Match Day to my conscious consideration while she was reading the Sunday Boston Globe. She announced that there was an article entitled “The pipeline of ER doctors is drying up: Hundreds of positions in emergency medicine are going unfilled because of huge structural problems in American health care.” The article was written by Emily Silverman who is an Internist in San Francisco and Jay Baruch who practices Emergency Medicine and is a professor of emergency medicine at the Alpert Medical School of Brown University. I liked the way they began their article:
Every spring, medical students count down the minutes to Match Day, when they learn where they’ll do their residency training. It’s a critical moment of transition for newly minted doctors — the culmination of years of hard work and sacrifice. For the rest of us, it’s a bellwether for the desires and plans of the next generation of doctors, those people we’ll be counting on to care for ourselves and our children.
This year, we’re stunned that over 550 of the roughly 3,000 residency spots in emergency medicine went unfilled. There were 219 unfilled spots last year and 14 left open in the 2021 match.
When I was planning my life in medicine the idea of formalized emergency medicine training was just being developed. The American College of Emergency Medicine wasn’t organized until the late sixties and Emergency Medicine was not recognized by the AMA as a specialty until 1972. Most of the original members of the American College of Emergency Medicine were not the products of training programs, but they were “grandfathered” into the specialty based on their experience in emergency rooms. I don’t remember seeing any emergency medicine training programs, although I am sure some must have existed by 1971 when I had my Match Day.
1972 was an important year in emergency medicine for me. As I was finishing my internship and its every-other-night rotation one of my residents asked me if I would be interested in “moonlighting” during my junior residency since the junior residency year was easier with mostly every third-night rotations. I was eager for extra income. Interns at The Brigham earned $9000 a year at the time, and junior residents did not make much more. I had two young sons and a wife who wanted to go to graduate school. I needed money. Having passed the National Boards and with my internship behind me, I was licensed to practice without supervision.
For years, Brigham residents in need of extra income had an inside path to moonlighting jobs at the Lowell General Hospital in Lowell which is about thirty-five miles north of the Brigham. My benefactor was headed to Chicago or New York for a fellowship and bequeathed his position to me. It was amazingly easy to get the job. There was no interview, no review of qualifications, and no paperwork. I guess the fact that my departing resident had recommended me was all that they needed in those more relaxed times. I had a brief phone conversation with the doctor responsible for the schedule. He just told me when to show up to go to work. I arrived for my first 12-hour shift in the LGH EW at 6 PM on a lovely summer evening in early July without much of a clue as to what I might expect. I was brimming with anxiety.
My preparation for the challenge was minimal by today’s standards. I had my surgical rotation as a medical student at the Boston City Hospital where I spent some time in the emergency room, so I had some proficiency in suturing lacerations and dealing with minor traumas. I had an elective orthopedic rotation at the Mass General and thought I knew something about fractures. During my internship, I spent a month in the Brigham ER managing medical emergencies. With that rudimentary training, I was ready to be the only doctor in a large community hospital for the next twelve hours.
My responsibilities extended beyond the EW. Besides seeing all the patients, adults and children, who came to the emergency room, I was charged with responding to emergencies anywhere in the hospital. If there was an event in the ICU or if any nurse in the hospital wanted the help of a doctor, I was the person called. There were local physicians whom I could call into the hospital to help me with disasters, and they all expected me to call them if I saw one of their patients, but I was most valuable to them if my presence allowed them to stay at home.
Working in an emergency room in a Boston teaching hospital is a team effort. There are plenty of more experienced people who will respond quickly to any request for help. The nurses are seasoned pros who would give me clues about what to do if things got hectic. In a teaching hospital getting help is almost instantaneous. There are many senior trainees and attendings for whom teaching and supporting less experienced doctors were more important than direct patient care or their research efforts. It did not take me long to realize that working alone with no one available to support me was going to be a totally different experience.
As I gained proficiency and confidence, I increased my hours up to thirty-six hours a week. I often worked one weeknight shift of 12 hours and a 24-hour shift on a Saturday or Sunday several times a month. On a typical 24-hour shift I would see 80 to 100 patients. I think the highest count was about 125. I continued to work at Lowell General until 1979 when my chief at Harvard Community Health Plan said I needed to stop moonlighting or leave HCHP and become a full-time emergency doctor. Along the way, as a fellow in cardiology when I rarely had night call, I also worked for a while in the emergency room at the Cardinal Cushing Hospital in Brockton where several of the other cardiology fellows also had moonlighting jobs.
As I reflect on my experience in the emergency room and as the only doctor in a hospital with more than 100 beds, I realize that I learned as much or more from that experience than I did in my residency. Having to be self-sufficient in the face of an emergency is a test. If you pass, you are more confident for the next challenge, but you are never absolutely sure that you can handle all that might be asked of you at the moment. The fact that you are in the middle of treating an elderly person who is short of breath and in pulmonary edema, does not protect you from a call from the ICU that announces that there is a patient there who has just had a cardiac arrest. I quickly learned how to work with and trust the nurses that made my survival possible.
As I continue my trek down memory lane, I am surprised by a few more observations. It was the seventies and in many places, drugs were a problem, but I never saw an overdose. Compared to an inner city experience today, I don’t remember treating a gunshot wound. I saw plenty of people who sustained auto accidents or other events while drunk. I saw fatal motorcycle accidents that must have been the result of too much speed on too wet a road. I saw women and even one child who had been sexually assaulted by family members and acquaintances. The encounter with the molested child required me to testify in court about my findings. I saw several severe burns. I saw many gender-specific accidents. Common injuries for men were lacerations and finger amputations from careless accidents with snowblowers, table saws, and chainsaws. I saw many women, but never a man that I can remember, who had lacerated a finger while doing dishes in soapy water that hid a broken glass. Split chins were common with children. On one occasion I made the mistake of allowing a mother to try to comfort her two-year-old while I was sewing up his split chin. I was surprised to hear a thump behind me. I turned around to find my patient’s mother passed out on the floor. She had a scalp laceration from hitting her head on the sharp edge of a metal trash can as she collapsed. I sewed up her wound, and I never made that mistake again.
Emergency physicians these days are much better prepared than I was, and I sense that their challenges are even greater than the ones that I experienced. Emergency rooms are crowded with non-emergencies because access to care in a non-emergency environment is so inadequate. When I was working at Lowell General there was an excellent state mental hospital less than a quarter of a mile away. Thorazine and politicians closed all of the mental hospitals so now many people who need inpatient psychiatric care are housed in emergency rooms until an adequate bed can be found for them.
The other manifestation of the closing of state mental hospitals in the eighties is that many people who suffer from chronic schizophrenia are now homeless and on the street. I am sure that during the peak of COVID, many emergency rooms were aptly described as pure bedlam (“Bedlam” was a famous psychiatric facility in England). The stress continued post-COVID as growing deficiencies in primary care staffing sent more and more sick, but non-emergency patients to the EW. When one contrasts the current bedlam in the EW, coupled with relatively low compensation compared to dermatology or radiology where a typical 9 to 5 workday is possible, or to well-paid surgical specialties like urology or ophthalmology, where there is less diagnostic ambiguity, is it any wonder that medical students are saying, “No thank you!” to a career in emergency care?
The authors of the Globe article ask critical “what and why” questions as they try to understand the deteriorating state of primary care and emergency care. They answer their own questions.
How could this be? For years, emergency medicine was a competitive specialty, highly sought after by medical students. Historically it has drawn a special pool of talent — those excited to manage a hemorrhaging trauma patient or fibrillating heart while also embracing the social justice mission of caring for anyone at any hour.
But it’s not just emergency medicine that is struggling to recruit students…The specialties increasingly shunned by students include emergency medicine, family medicine, and pediatrics.
What is driving these changes? We can point to various incentives. Money, for example. The average medical student graduates with $200,000 in debt, not including undergraduate loans, so it makes sense that they’d look to lucrative specialties to pay it back. Another is lifestyle. The flexible hours of physical medicine or the peace and quiet of the radiology suite might be preferable to the night shifts and chaos of an unsafe, understaffed emergency room.
The plight of emergency medicine and primary care is complex. There are many factors that could cause a medical student to avoid primary care and emergency medicine:
…the American College of Emergency Medicine mentions possible factors that steered applicants to other specialties this year. They include increasing clinical demands, workforce projections, emergency department crowding, the impact of the pandemic, and the increasing corporatization of medicine.
Those answers all make sense to me, but what might be the deeper issues that the authors believe are contributing to this disturbing trend? I have bolded an important part of their answer.
The specialties losing talent are ones that address the whole patient, not just a single organ or system. They require doctors to sit with suffering and uncertainty — to engage with the messy reality of multiple narratives, integrating the biological and social into a tentative, coherent whole…This takes time and presence, which is nearly impossible in an assembly line system that allots 15 minutes per primary care appointment. A recent study showed that primary care doctors would need 27 hours in a day to provide the care recommended by medical guidelines.
Their observation is not news to me. I feel that they have identified the core of our collective problem. The specialties that are suffering the most are the ones where really connecting with the patient is critical to successful care, and where there is little time to connect. Practicing primary care or emergency medicine means that you are challenged daily by the lack of time to manage the ambiguity and uncertainty that is associated with providing care. If you care about patients or just care about your professional career and emotional survival, being required to make critical decisions in a rush and with inadequate knowledge of the patient is not a sustainable position. Let me explain from my own experience.
Over more than forty years of practice, I am sure that I had to make many decisions where the complexity of the situation or the ambiguity created by a need for data that was not available might have led to an error. Daniel Kahneman talked and wrote about thinking “fast and slow.” When dealing with another person’s life, it is nice to have the advantage of thinking “slow.” What the authors describe, and what I and most of my colleagues have experienced, is the necessity of making most decisions “fast.” You survive on reflex decisions. Some people use the metaphor of being on a fast-moving treadmill. My image was the work was like standing by a rapidly moving conveyer belt with patients going by at a high rate of speed. You know that only a few of them have a problem that must be identified and addressed immediately, but they are not labeled and in most ways, all the patients look the same. The critical task is to recognize the few patients who need attention immediately or who have a potentially serious problem and pull them off the conveyer belt and put them in an environment where they can be more closely observed, and where you have the luxury of thinking “slow.”
The data about “correct practice” requiring 27 hours a day is accurate. The fact that the time allotted for each visit is usually fifteen minutes means that if you are going to stay on schedule you must skip things you should be doing. Even when you cut corners, there is little time for questions and interactions, even less time for thought, and more opportunity for missing critical pieces of evidence that might contribute to solving the patient’s problem.
With the necessity to “do something” many practitioners order a lot of tests with the hope that one of the tests will be a clue to the diagnosis, or if nothing else, suggest to the patient that you took their complaint seriously. It’s a move that is a combination of “cover your a–” and proof that you “give a sh–.” With our concerns about cost, superfluous testing was not my major coping mechanism. I opted for violating the fifteen-minute allotment, scheduling frequent return appointments, and staying in close contact with my patients through emails and phone calls. My cell phone number was on my business card as soon as we had cell phones, and I added my personal email when email became available. I urged people to contact me if anything changed.
There was a cost to my methodology. My schedules were always overbooked. I was always late. I was always behind in my documentation. My private time and family time were compromised. I will say that patients rarely abused the access that I offered. If I heard from someone, it was usually a message that I was glad that I got. Obviously, my methodology had many personal and organizational downsides. I am certain that my practice patterns contributed to the failure of my first marriage. My children suffered from the fact that my work was always with me. I am also certain that just as over-ordering tests adds to waste and cost, my methodology also added cost to the system.
There was also a cost for patients. Most of my patients knew that when they accepted an appointment for 3 PM, it might be 4 or later before I saw them. They also knew that I would not rush them out. It was a transaction. I would try to provide the experience that was wanted if they were willing to wait. It is a reality that if you only go over by 4 minutes during every 15-minute appointment in a four-hour clinical session you will be an hour or more behind by the end of the session.
Every doctor that has not quit in frustration has developed some way to manage the conflict between the schedule and the patient. Some doctors protect themselves by scheduling patients that won’t show up, or adding catch-up appointments that could have been managed by phone or other means. They are also reluctant to take on complicated and potentially needy patients because of the time it takes to deliver care to them. What is most easily lost, no matter what the doctor decides to do, is the opportunity for the patient to be known and heard. The result is often a missed diagnosis. The failures add to the tendency for doctors to “burn out” and for patients to be justifiably angry.
In this day and age, we count the number of people who have been injured or have died from the use of assault rifles. It would be hard to discover, but if we could get the data, I feel certain that the 15-minute appointment driven by fee-for-service finance has killed or maimed an amazing number of patients and providers while leaving millions of those who survive with a sense of having been abused. The authors see it much the same way.
…there is a cultural problem. Both within and without the halls of medicine, this comprehensive way of caring for people is viewed as “below’’ doctors, who are more useful for their technical skills like scoping or stenting or operating. But what about efforts to understand a particular patient’s habits and stresses and possibly prevent the need for a cardiac stent? Or to figure out when the ER patient’s stomach pain is complicated by mental health challenges or loneliness? The system doesn’t incentivize us to deal with these questions.
I like the fact that the authors stress getting to know the patient and hearing them because “knowing the patient” is critical to optimal care even if the time it takes to “know” is not “compensated.” Patient-centered practice is harder to measure than the number of tests that were read or procedures performed. The authors imply that what patients really want we either can’t or won’t deliver. We are constrained by systems issues that frustrate patients and their care providers. They end their piece by suggesting that what happened on “Match Day” should concern us all.
As a society, we claim we want holistic and compassionate care. We notice our doctors are distracted, or callous, or incapable of seeing us in the ways we most want to be seen…We crave a more integrated whole.
But the Match Day results show us we are getting farther from that vision, not closer to it. If we don’t find a way to capture value in holistic care, to supply doctors with the time and resources they need to practice the art of medicine, to incentivize students to shoulder the responsibility of the entire patient and not just one body part, health care’s crisis will only deepen.
The Sunday Boston Globe also offered a piece in the same edition on its editorial page about the compensation and worklife of physicians in training programs. Let’s face it. Interns and residents have always worked long hours. There has always been the concept that a trainee must virtually “live” at the hospital (training programs are called residencies) to acquire all the experience and knowledge necessary to be a competent practitioner.
You learn a lot in medical school. I have called it a four-year vocabulary lesson. The clinical experience in medical school is only a “taste” of what is to come. We would like to think that it is the internship and residency that prepares doctors for practice. That is not entirely true. For most of us, we still have a lot to learn once our training is over. It takes years of focus and reflection to become the clinician that most patients are hoping for every time they see a doctor. If your day is always like running on a treadmill or standing by a conveyer belt trying to grab the patients that are really sick, then you may never reach an acceptable level of performance that produces better care and patient satisfaction.
To get better, doctors must have the time to reflect on what they have seen and the errors that they may have made. It helps to be able to have time to discuss difficult cases with colleagues. These days when you need to cram 27 hours of activity into one long working day those reflections and conversations rarely occur.
The explosion of medical knowledge and technology has led to longer and longer training programs that lead to increasingly narrow fields of vision. We use five or six years of residency and fellowship training to produce a doctor that is very good at doing an angioplasty, but may not remember much about the infectious disease or neurology, and never has time to more than superficially meet the patient who is terrified about what is about to happen as they lie under the sheet in the cath lab.
What is also true is that broader personal development, physical fitness, and the ability to function with interpersonal grace are hard to maintain if you have experienced four or five years of sleep deprivation working eighty hours a week while several hundred thousand dollars of personal debt hangs over your head. Oh, I should add that if you desire a relationship, your partner needs to be a paragon of patience and understanding because frequently you will not be completely present even when you are present. Sleep deprivation does not foster good manners and concern for others. More than once after working for more than 24 hours, I have gone to sleep waiting for a stop light to change from red to green. You can imagine that after I had been napping at stoplights, I was not a very good conversationalist when I finally arrived at home.
I was reminded by the editorial that since 2003 the work week of doctors in training has been theoretically limited to 80 hours with no one shift longer than 24 hours. During my every-other-night on-call internship in 1971, I was in the hospital at least 100 hours a week if not more. There were a few more hours away from the hospital in the second and third years which gave me the time to moonlight at the Lowell General. I would argue that the 80-hour week is still much too long. The editorial points out that European trainees work a 48-hour week.
One problem that prevents us from applying the European hours to our training programs is that we could not staff all of the residency programs if we went to a mandatory maximum that was shorter than 80 hours. We don’t graduate nearly enough doctors to staff every hospital that depends on their labor which creates workforce problems in hospitals from unfilled residency slots which also means that there are too few graduates from our training programs to replace the physicians lost to retirement and burnout each year. The problem is made worse by an aging and growing population that is living longer with better chronic disease management that is often provided by nurses with advanced practice skills. Even if we were graduating enough doctors in 1971, we have now lagged too far behind to have an adequate workforce anytime in the next decade.
The editorial also identifies current concerns with resident pay. Fifty-two years ago I was paid $9000 for my 100-hour work week. That was not adequate which was why I needed to moonlight. Currently, trainees make $80,000 and even $90,000 with housing bonuses. I applaud that but comparisons are hard. Gasoline was 30 cents a gallon and my rent was a few hundred dollars in 1971. A new Volkswagen sold for about $1700. I am not sure that today’s trainees are much better off than I was. The numbers just look different. The concerns about hours and pay underline the need for radical changes if we expect to maintain our position as the absolute worst-performing system of care among the world’s richest nations, and not fall further into the health outcome experience of third-world countries for three times the cost. The editorial presents a quote that is a huge understatement:
Caitlin Farrell, an emergency room physician at Boston Children’s Hospital and immediate past president of the Massachusetts Medical Society’s resident and fellow section. “What residents and fellows have known for a long time is we really need a systems-based approach to a change in the institution of medical education.”
There are more disturbing facts to support the need for radical change:
…A recent Massachusetts Medical Society report on physician well-being found that 74 percent of residents and 79 percent of fellows reported symptoms of burnout. No residents felt they mattered to their organization “a great deal’’ and 29 percent felt they mattered “not at all.’’ The Centers for Disease Control and Prevention says someone who is awake for 24 hours is as impaired as if they were drunk.
The editorial ends with what I would say is a sad acceptance of a problem that may be too big to solve. Perhaps our inability to adequately staff our current methodology of care calls for a radical redesign of the training programs, and the methodology of how care is delivered. The article and the editorial sound the warning, but will there be an effective response? I doubt it. If we can’t effectively address gun violence or global warming what would give you confidence that we can insure the delivery of adequate care to every American in the future when we can’t do it now? My guess is that individual clinicians will continue to do what I did which is to construct self-preserving strategies within a system that refuses to change. The sad reality is that as our surviving providers become more and more stressed we and our future generations will be doomed to a declining system of care that can’t equitably preserve the health of the nation.
We Left Winter Behind
There was a light dusting of new snow and the temperature was 21 degrees on Thursday morning as we rolled out of our garage a little after 6 AM so that we could get to Manchester in time to catch an 8:35 AM flight out to the West Coast. As today’s header indicates, our destination was the mountains and redwoods just north and east of Santa Cruz where we were eager to see two grandsons and their parents. COVID worries and inflated travel expenses make me reluctant to travel, but Zoom can’t touch the joy to be experienced by having the chance to read a story to an eager listener who is sitting on your lap.
As we were flying across the country a rag-tag Red Sox team minus many of its stars from recent seasons struggled against the once lowly but now improved Baltimore Orioles. One game doesn’t make a season, and there is more to love about baseball than just winning. It is a seven-month soap opera filled with immediate and long-range concerns where multi-year strategies are necessary for even occasional success.
I am looking forward to faster games provided by putting a clock on the pitchers and hitters. I also was annoyed by the shifts that so many teams have deployed over the last few years, especially against left-handed hitters. The second baseman does not belong in shallow right field and the shortstop should not be waiting for a ball where the second baseman should be standing. I’m old school. If it takes innovation to get back to a game that feels “old school” then I am for it.
When we were landing in San Jose we turned on our cell phones and discovered that the Manhattan grand jury had indicted our ex-president. What comes next? Will the Fulton County DA now have the courage to announce the stronger case that she has? What I do know is that we are in for plenty of political drama, and that the Sunday morning talking heads of politics plus the late-night comedians will have plenty to talk about for many months to come.
More than anything I hope that while we are away spring will come to our little world. It’s been a strange winter with temperatures running about five degrees above average, and a couple of big snowstorms late in winter that resulted from the systems that were creating violent weather on the West Coast and in middle America before finally reaching the northeast. As a result of the crazy weather, I have never seen California look greener than it does now.
I am going to give up monitoring the news this week. I worry about the war in Ukraine and when the next shooting at school might occur. Who knows what will happen next in the Trump drama? I have no control over any of those concerns, so I will focus on my grandsons while hoping that the world they will know when they are my age and visiting their grandchildren will be a world where there are no social inequities, no deaths from gun violence, and no carbon overload of the atmosphere. I hope that our country will still be a democracy. If I could have but one wish for my grandchildren and for yours, it would be that by the time they are my age we will be living in harmony with all our neighbors. Those are my hopes as we enter Holy Week.
I hope that you have something to look forward to and that you will be with someone you love to see this weekend.
Be well,
Gene
