An ongoing dialogue on HIV/AIDS, infectious diseases,
June 23rd, 2019
Advice to Incoming Subspecialty Fellows — Don’t Underestimate or Belittle Your Interns and Residents
Around a million years ago, early during the first year of my ID fellowship, a medical intern consulted me about an elderly patient with a urinary tract infection.
Me: Does she have a catheter?
Intern: I don’t know.
Me: Has she been admitted before with a UTI? Any cultures?
Intern: I think so — wait, I’m not sure. Let me check her chart.
Me (testy): Nevermind — we’ll come by and see her. (Slams down phone.)
It might have been a busy day for me. Or a late afternoon consult. For whatever reason, I was feeling pretty fried.
Over the next week, I channeled my frustration with this exchange by citing it several times as an example of the general cluelessness of the current interns and residents — house staff at the very fine hospital that kindly had accepted me to their fellowship.
But wait. That can’t be right.
Indeed, let the record show that I was emphatically wrong — the interns and residents during my fellowship were outstanding. This particular intern had a PhD in immunology and was just getting started as a doctor. No surprise that not all the details were immediately at her fingertips.
I bring this up today because right now, in many teaching hospitals, the interns have already begun, and the subspecialty fellows are waiting in the wings. Most start in the next week or so.
It’s therefore a perfect time to take on this commonly held (and sometimes, alas, openly voiced) opinion by some subspecialty fellows as they grow into their new roles:
These interns and residents are weak!
There are numerous triggers to this ungenerous thought. Most involve consults deemed “inappropriate” by the subspecialty fellow, for a variety of reasons:
- Consult called without having complete information. (My example.)
- Consult called without asking the right question. (How can they always know the right question if they need help on a case?)
- Consult called “too early” in the admission, without the house staff doing the full initial work-up.
- Consult called “too late” in the admission, with the house staff mismanaging the case before calling the consult. (Look how the residents can’t win here, with both #3 and #4 suggesting some magical precise correct time for calling a consult.)
- Consult called too late in the day.
- Consult called by the medical student, which is deemed insulting to the newly minted fellow. (Oh come on.)
- Consult called for something the fellow would have handled without a consult when they were residents.
I bolded this last one since it’s probably the most common example. (Junior faculty sometimes succumb to this one as well. It’s an early form of, “In my day …”) What weakness!
So let me emphasize, again, by noting, emphatically, that this perception is a total illusion.
There is zero evidence that interns and residents are weaker, less thoughtful about patient care, and less thorough than we were during residency, whenever and wherever that may have been.
How do I know? Because there’s a control group — those who do their fellowships in the same hospital as their residency. These fellows sometimes cite weakness in residents who were, until very recently, their colleagues. And folks, it’s literally impossible that suddenly and unexpectedly, the entire house staff regressed, losing all their clinical skills when said fellow graduated.
So what’s behind this negative line of thought? And what can we do to correct it?
To answer these questions, a few months ago I posted the following:
Residents are never as good today as they were when we trained, and also never as good as hospital X than they are where we did our residency, wherever that might have been.
This isn't true, of course–so why are these views nearly universal? And what can we do about it?
— Paul Sax (@PaulSaxMD) April 20, 2019
Encouragingly, many responded that they feel that today’s house staff are wonderful.
But some acknowledged that the phenomenon exists, and offered various thoughts about its origins. I like this response, from ID colleague Dr. Andrej Spec (who may be better known on ID Twitter as @FungalDoc):
Nostalgia. That, and as we get better, it becomes easier to see the mistakes that we were oblivious to previously. The solution is to keep remembering the times we made mistakes. So that we put ourselves in perspective.
Or, from a rheumatologist (@Doctorkuch):
Thinking that everything you know now, you knew then (false!). #constantlylearning
These comments get right to the heart of the problem. We spend the years of residency honing our craft, becoming better at what we do through clinical experience, teaching conferences, and reading. By the time we are in our last year of residency, there’s a wonderful sense of mastery — that’s the good part.
The bad part is that we may unfairly expect similar mastery from our junior trainees.
So the next time we feel like criticizing an intern or resident for not having all the information, or not consulting at the right time, or calling a consult on a case we think we would have handled ourselves without a consult — remember what it was like to start your training.
And remember, this doctoring thing is hard — a lifelong exercise in learning, and trying to get better.
It may not be quite as difficult as getting this “smart” light bulb to work, but it’s close.
So how many ID docs does it take to change a light bulb?