House Officer: Becoming a Medical Specialist

258 Pages·1988·4.693 MB·English

by  Richard L. Cohen M.D. (auth.)

HOUSE OFFICER
Becoming a Medical Specialist
HOUSE OFFICER
Becoming a Medical Specialist
Richard L. Cohen, M.D.
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Plenum Medical Book Company • New York and London
Library of Congress Cataloging in Publication Data
Cohen, Richard L. (Richard Lawrence), 1922·
House officer: becoming a medical specialist I Richard L. Cohen.
p. cm.
Includes bibliographies and index.
ISBN-13: 978-1-4615-9527-4 e-ISBN-13: 978-1-4615-9525-0
DOl: 10.1007/978-1-4615-9525-0
l. Medicine-Specialties and specialists-United States. I.. Title.
[DNLM: l. Education, Medical, Graduate-United States. 2. Internship and Residen·
cy. 3. Specialties, Medical-United States. W 20 C678h]
R729.5.S6C64 1988
61O'.7'1173-dc19
DNLM/DLC 88·17930
for Library of Congress CIP
© 1988 Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
Softcover reprint of the hardcover 1s t edition 1988
Plenum Medical Book Company is an imprint of Plenum Publishing Corporation
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
ACKNOWLEDGMENTS
The task of thanking everyone who made a contribution to a volume of
this type is a large though pleasant one. Without question, the greatest
debt of gratitude is owed to the 52 very busy, often very tired interns
and residents -who gave their valuable time to be interviewed. Even
more importantly, they shared their thoughts and feelings to a degree I
could not have predicted. Without their contribution, this book would
not exist.
Dr. Thomas Detre not only encouraged me to pursue this work, but
through his good offices, encouraged many senior department chairmen
and training directors to cooperate in its implementation. He has
provided thoughtful counsel both during the period of information col
lection and, later, during my struggles to get all of this on paper in
readable form.
Thanks also go, of course, to all of the faculty members, chief resi
dents, and training directors who helped interpret this work to some
times skeptical groups of house officers in their departments and who,
undoubtedly, were responsible for the unpredictably large number of
volunteers.
Several full-time hospital physicians and private practitioners were
kind enough to read many of these interviews and to provide helpful
comments. Among these were Drs. Lee Bass, Peter Henderson, Joseph
Horton, Jonas Johnson, Michael Rancurello, James Reilly, Paul Scott,
Arnold Sladen, and Barry Uretsky. Maggie McDonald and Barbara Ep
stein also provided suggestions and encouragement.
My secretary Karen Hickey-Rhinaman provided continuity of care
during the entire process, doggedly tracking down elusive house offi
cers, scheduling and rescheduling broken appointments, transcribing
taped interviews, and finally, paying close attention to the production of
the manuscript.
Last but not least, my deepest appreciation goes to Janice Stern, my
editor at Plenum, who proved to be an author's dream, smoothing a
v
vi ACKNOWLEDGMENTS
furrowed brow here and providing an encouraging shove there, all the
while making sure the writer's self-esteem did not sag below the critical
level that would interfere with productivity.
My apologies to anyone I have neglected. As any reader can see, this
not overly long work required the efforts of a great many people.
R.L.e.
A NOTE TO THE READER
This book contains many quotations from interviews with interns
and residents, and there are frequent transitions from text to quoted
material. In order to assist the reader with these transitions, upright and
inverted triangles have been employed.
A Glossary has been included at the end of the book for the non
medical reader.
CONTENTS
1. Introduction 1
I. THE "MEDICAL" SPECIAL TIES
2. Internal Medicine 11
3. Pediatrics 21
4. Psychiatry 33
5. Neurology 45
6. Dermatology 57
II. THE "SURGICAL" SPECIALTIES
7. General Surgery 65
8. Obstetrics and Gynecology 75
9. Neurosurgery 87
10. Otolaryngology 99
11. Ophthalmology 107
12. Orthopedic Surgery 113
III. THE "HOSPITAL-BASED" SPECIALTIES
13. Anesthesiology 123
14. Radiology 135
15. Clinical Pathology 143
vii
viii CONTENTS
IV. THE "GENERAL" SPECIALTIES
16. Emergency Medicine 155
17. Family Practice 167
V. GENERIC ISSUES
18. Interpersonal and Developmental Issues 179
19. Environmental Stresses 203
20. Background and Literature Review 215
VI. CONCLUSIONS AND RECOMMENDATIONS
21. Summing Up 237
22. Some Words of Advice 245
Afterword 253
Glossary 257
Chapter 1
INTRODUCTION
This book is about how young physicians experience training as medical
specialists. Much attention is now being drawn to the stresses of post
graduate medical education, their potential negative impact on the qual
ity of patient care, and the manner in which these stresses influence the
professional and personal development of the physicians involved.
The entire focus of this book is on the firsthand experience of 52 such
physicians enrolled in 16 different medical specialty training programs.
Because the evaluation of stress is largely a subjective one, I have elected
to approach the question through the perception and the cognitive pro
cesses of the trainees themselves.
THE DOCTORS
The "subjects" of this work are 52 young physicians who volun
teered to be interviewed confidentially and anonymously during the
1986-1987 academic year. They represent the specialties of anesthesiol
ogy, clinical pathology, dermatology, emergency medicine, family prac
tice, general surgery, internal medicine, neurology, neurosurgery,
obstetrics and gynecology, ophthalmology, orthopedic surgery, oto
laryngology, pediatrics, psychiatry, and radiology.
Because this inquiry depended entirely on a volunteer sample, it was
not possible to ensure a wholly representative population. For instance,
not a single minority house officer stepped forward. The actual demo
graphic breakdown is represented in Table 1. Although all of the subjects
did not come from the same training center, an effort was made to com
pare the characteristics of this population with that of a large, metro
politan, university-affiliated medical center. The demographics of that
population are represented in Table 2. As can be seen, there are several
discrepancies, although most segments of the population are well repre
sented, with the exception of minority groups.
1
2 CHAPTER 1
METHOD
I recruited volunteers by approaching their training directors and
their service chiefs, explaining the specific purpose of the project, and
requesting permission to contact the house officer group in that specialty
to solicit participants. Because legal and ethical consultation reinforced
my judgment that this was not a research project, formal informed con
sent was not a part of the procedure. Nevertheless, the project was
carefully explained to each resident group, and the right to withdraw at
any time was made explicit, along with a full guarantee of anonymity.
The residents were assured that either the results of this work would be
reported in the aggregate, or if specific illustrations were used, the iden
tity of the individual would be thoroughly disguised. This assurance also
TABLE 1
Characteristics of House Officers*
Medicala Surgicalb Hospital-basedc General TQtal
(18) (18) (9) specialistsd (7) N %
Gender M=11 M = 17 M= 7 M=7 42 80.8
F= 7 F= 1 F=2 F= 0 10 19.2
Age <25 = 1 <25 = 0 <25 = 0 <25= 0 1 1.9
25-29 = 14 25-29 = 11 25-29 = 7 25-29 = 7 39 75.0
30-35 = 2 30-35 = 6 30-35 = 2 30-35 = 0 10 19.2
>35= 1 >35 = 1 >35 = 0 >35= 0 2 3.9
Race W= 18 W = 18 W= 9 W= 7 52 100.0
B= 0 B= 0 B=O B=O 0 0.0
0= 0 0= 0 0=0 0=0 0 0.0
Marital M= 8 M=11 M= 8 M=3 30 57.7
status 5= 9 5= 6 5 = 1 5= 2 18 34.6
D= 0 D= 1 D=O D=O 1 1.9
0= 1 0= 0 0=0 0= 2 3 5.8
Children 6 7 4 4 21 40.4
Postgraduate 1= 3 1= 2 1=1 1= 0 6 11.5
year of 11= 9 11= 5 11=2 11=5 21 40.4
training III = 6 III = 6 III = 4 III = 2 18 34.6
IV= 0 IV= 0 IV = 2 2 3.9
V= 0 V= 4 4 7.7
VI = 1 1 1.9
*N = 52. Key: M, male; F, female; >, greater than; <, less than; M, married; 5, single; D, divorced; 0,
other; W, white; B, black; 0, other. aInternal medicine, pediatrics, psychiatry, neurology, and der-
matology. bGeneral surgery, obstetrics and gynecology, orthopedic surgery, otolaryngology, ophthal-
mology, and neurosurgery. cRadiology, clinical pathology, and anesthesiology. dEmergency medicine
and family practice.
INTRODUCTION 3
served the purpose of allowing the fullest possible freedom to express a
range of views about training and about the faculty without concern
about later penalties.
In many instances, the service chief or the senior resident in the
specialty offered to recruit participants himself or herself, expressing
enthusiasm about the work and the desirability of eliciting this informa
tion. Only limitations on my own time controlled the size of the sample.
More volunteers than I could adequately interview were available in
several of the specialties.
As a result of my own experience in counseling residents about
either personal difficulties or career choices over the past 35 years, and in
the hope of collecting reasonably uniform data, I designed a semistruc
tured interview that I followed in all instances. The interview format was
typed and photocopied and explained to each resident at the beginning
of the interview so that he or she could more fully participate and so that
there would not be any future surprises. This outline appears in the
appendix at the end of this chapter.
All interviews were tape-recorded with the explicit permission of the
resident. The tape recorder was placed in full view and was not turned on
until the resident concurred. The approach of the interview was funda
mentally developmental. It reviewed the resident's current assignments
TABLE 2
1986-1987 Statistics*
Number of
university
residents (555) Totals Percentages
Gender M = 406 73.0
F = 149 27.0
Age <25 = 7 1.3
25-29 = 342 61.6
30-35 = 161 29.0
>35 = 45 8.1
Race W = 524 94.4
B= 13 2.3
0= 18 3.2
Marital status Approximately one half were married.
'Key: M, male; F, female; W, white; B, black; 0, other.