Saturday, August 9, 2008

Residency

I've been thinking about this a lot lately, so I am writing this mostly to work it all out in my head. Most of you will find it utterly boring, unless you are applying for residency this year, then maybe it could be helpful, but otherwise, feel free to just skip it. Hopefully our next post will mostly be cute baby pictures - much more fun.
The background - As most of you know, Mitch and I are both doctors, at very different stages in our careers. I am a Pediatrician, not currently practicing. I finished my Residency (at UT-Houston) in 2006, did a Chief Residency, and now stay home with my kid(s). Mitch is currently an Internal Medicine Resident (at Scott & White) in his 2nd year, and contemplating fellowship options. During the year that I was a Chief Resident, I had many opportunities to learn about the behind the scenes parts of running a residency program and a hospital. It was really enlightening and has impacted some of my opinions about "the way things should be". With that fundamental bias in mind - here we go.
Of late, it seems that the differences between UT/Hermann and Scott & White have been really making themselves felt to me. I'm not talking about the obvious - big hospital in a major medical center vs. smaller hospital in a small TX town, although I think that underlies many of the differences, but rather the smaller, day-to-day things that make life more or less comfortable. We're talking perks here. I know that seems like a "whatever, get over it" kind of thing, but I think that the way that you treat the people who do the greatest majority of patient care work in your institution says something about your institution and what it values. Residents work 80+ hours per week, cover the hospital nights and weekends, and basically do the work of 2-3 "physician extenders" and in so many cases, don't get the credit that they deserve.
So, first major difference, and this is one where I think S&W may be on the right track. At UT they have a very traditional mindset about call. As a resident myself in 36 months of residency, 29 of those months included some element of either overnight call or night shifts, mostly overnight call. We were generally on call every fourth night, so we spent two "normal" 12-14 hour days at the hospital and on the other two days worked 30 hours straight. Sounds gruelling - it is. This is pretty common practice, especially among pediatrics programs. There were some pretty compelling reasons for the amount of call that we had. We covered all of the pediatric and neonatal care for 3 major hospitals, so we needed a lot of warm bodies, but I suspect that a little creativity could have alleviated some of the burden. At S&W they are attempting to minimize the amount of overnight call that the residents take. In some ways I think this has been successful, but in other ways has created more problems. Not unexpected when attempting to change such a firmly entrenched paradigm. The residents are still working 80 (sometimes more) hour weeks, but they get to sleep at home in their own beds more of the time. There is something good to be said for this!
Another fundamental part of employment in general is the compensation package. Here is one place where most programs are fundamentally similar. Pay scales are about the same across the nation and benefits are at least similar. Not much to say here, but if you are applying to residency now, be sure not to overlook this part of the equation. It makes a difference.
On to other perks. One of the fundamental differences that I have noticed between UT-H and S&W is the lack here at S&W of a resident advocacy group. At UT we had not only our completely amazing program director, who was a huge advocate for the residents in my program, but we had a hospital wide resident advocacy committee, which was comprised of residents and faculty and which helped to advocate for the residents in cases where the hospital made decisions that effected us. One huge example is resident parking. This is actually a big issue in Houston, where space in the medical center is at a premium. For the average person, parking costs ten dollars a day, with contracts available for $200-300 monthly, depending on how close you want to be. As residents, you not only keep crazy hours, but make almost nothing, so none of us could have afforded to park close in. When I began my residency, the hospital provided parking in a lot across the street from the hospital, but as the hospital constantly was expanding, that very valuable piece of real estate was taken away to build a new clinic building, and we were left with nowhere to park. Our resident advocacy group went to work and eventually made an equitable deal that gave the residents parking close in, but didn't cost the hospital or med school a ridiculous amount. Here at S&W, there is no such advocacy group, so when the hospital decided to arbitrarily take away the money that they had been providing for resident meals (more on that later), there was no one to go to bat for them. In some cases, the programs ponied up and foot the bill, but not Internal Medicine.
Food money - another bone of contention. Most residency programs offer some sort of on call meal stipend to their residents. When you are in the hospital for 30 hours, food is not a high priority - the patient in room 316 with the brain bleed is. As such, most places to provide either monetary compensation or actual meals to the busy resident. When we came to S&W last year, this was the case. They were actually quite generous - providing daily lunches for the residents as well as on-call meal money at the S&W cafeteria. This was mostly funded by the hospital, but the funding was recently cut and nothing has taken it's place, so I spend a lot of time taking food to Mitch at the hospital.
As an aside, I think that many of these little things represent a fundamental difference between a program located at an enormous hospital in a major medical center and a smaller community hospital in a little town. I know S&W likes to think of themselves as a major player in the health care scene, but we call that delusions of grandeur. I think that as the hospital and supporting community get bigger, there are just more resources available for utilization. I am not making a value judgement about the program itself, or the quality of education. Just the perks. I also think that my situation was a fairly unique one, as we had a competing institution (Baylor College of Medicine) literally right across the street. As a result, we were able to make comparisons much more easily. Free market economy works here, too. Here at S&W, there really isn't anything like that - the closest comparison is Austin, whereas I could probably have hit Baylor with a spit wad from the window at Hermann. Some people probably did.
OK, back to the main topic - perks. Have you thought about those handsome white coats that doctors get to wear once they cross the stage and get their real MDs (or DOs)? I didn't give them a second thought. They were provided by the program, monogrammed for us, and cleaned weekly by our cleaning service. I thought that was just the way it was. Baylor did that, too. We all had nice, white snazzy coats. Made you feel like a real doctor... Here at S&W, you buy your own coats, monogram them yourselves, and get them dry-cleaned or launder them yourself. I know, it seems like another small thing, but I think it is representative of the relatively low esteem that the hospital has for it's residents. And have you ever tried to starch one of those stupid things!! What a pain!! It was also brought to my attention the other day that there could be a safety issue, as many times there are biohazard materials on the coats themselves. Mitch doesn't often make it through a code without getting blood on a sleeve, which he brings home and I clean. I never thought about it really (I mean, how many times have I gotten some kiddo's blood/pus/urine/feces on myself), but it is an issue. A corollary to this is scrubs. My hospitals all provided scrubs and cleaned them. Again, although S&W did provide three of the cheapest scrubs I have ever seen, they do not clean them.
Oh, this is getting long, and turning into a bit of a rant, so I'm going to stop (and try to catch an hour of sleep before Logan wakes up). If you are actually still reading this - wow, thanks. I'll be here all week...

3 comments:

Sarah Colley said...

I did, actually read it. Not at 5:16 am, you understand , , ,
Pretty amazing stuff. This is why union-backed laborers ocaissionally go on strike just for perks -- they DO matter.
So: do we have to wait another week to see where you are going with this?
Mayhaps Mitchell could transfer his residency to ETMC in Tyler - I have it on good authority that the food in their caf is excellant, although I don't know if residents pay for it or not.

DNAgallows said...

That was great! I'm not sure I still want to go into Pediatrics. Just kidding. I would love to hear any more advice or words of wisdom as I set out to find the "perfect" program. Call schedule is a big deal as well as those little things that make big differences (perks if you will). Thanks for the insights. David

jaredski said...

I'm in Pathology at S&W and we used to get lunch every day. The reasoning was that since we had to attend some educational conference during every lunch hour, we should have lunch delivered. They ended that in February.

I heard it was because the hospital had to refinance their debt, which they do every 6 months. With the credit crisis that hit right then, they had to refinance at a ridiculous rate. So every department was told they had to cut budgets. Basically, some reckless, greedy Wall Street bankers ate my lunch.

We lost lunches, funding for trips to present research, and book money. I'm done with residency now, but for the residents just starting it's a raw deal. It's like a bait and switch.

When the credit crisis settles down, are they going to reinstitute perks? We'll see. They need to do something if they want to attract good people.