Medicine has a fraught relationship with money. Dealing as they do with matters of life and death, doctors are loath to assign a dollar value to human life, preferring to avoid the subject altogether and instead provide the care that they deem appropriate no matter the cost. Insurance companies, on the other hand, make their business in rationing health dollars and have no such qualms: the consensus among them is that a human life in this country is worth about $50,000 per year (though new data suggests that number may be closer to $130,000). Controversial though this may be, it has real implications for which treatments are made available to which patients. There is no getting around the fact that illness is expensive, and the return on investment diminishes the more ill you are.
The one exception to this intrusion of financial matters into health care, I would argue, is academic medicine. Residency is, in many ways, an idyllic time (another controversial statement). Residents are free to experiment (within the bounds of patient safety, of course), to order tests that may not be “cost-effective,” to pursue a diagnosis that may be purely academic and may not have any true bearing on the patient’s prognosis or hospital course. This is the luxury of being a resident: You are not yet beholden to a hospital’s bottom line. And nor should you be. The resources of the hospital are at your disposal, all in the service of making you a more judicious clinician. In starting a training program, a hospital is entering into an implicit contract that the resident comes first; that educating the next generation of physicians takes precedence over turning a profit.
And yet there are hints that this is not so. At large urban academic centers, turnover is high, and hospital stays relatively short, such that one barely finishes typing up an admission note before the discharge summary is due. And the hospital is packed to the brims: Where I work, virtually no space is safe from being converted into a patient “room,” including hallways, a day room which was purposed as a space for patients and families to spend time, and a treatment room which was meant to be reserved for procedures.
The upside of this: More Medicaid and Medicare dollars for the medical center. The downside: Increased strain on house staff, nursing and support staff, not to mention the safety concerns that arise with parking a sick person in a hallway. Residents are frequently assigned to teams led by hospitalist attendings, who, under many compensation schemes, are incentivized to maintain high patient turnover (the industry term is “productivity”). This essentially reduces house staff to the level of worker bees in dutiful pursuit of an attending’s bonus, which can account for a substantial portion of their income. At my hospital, house staff are even subjected to an extensive online training about documenting to maximize “charge capture,” a choice piece of euphemistic medical-ese.
These are concerns for the hospital, without a doubt, but they should not be the concerns of residents. Residents occupy a peculiar role in the hospital, somewhere in between that of a medical student and a full employee. They are a special kind of labor force: one which the institution is allowed to work overtime without paying overtime or providing mandated breaks or other benefits. And this is where that implicit contract comes into play: The reason hospitals are allowed to get away with this is that we all agree it’s for our own good. Because the hospital has taken on the burden of educating us, it can work us long hours and pay us roughly the same wage as the cleaning staff for much more highly-skilled work. And we don’t complain because we are here to learn, and it’s is all part of that process and this is the way it’s always been.
But what about when learning takes a backseat? What about when sheer patient volume squeezes out time for reflection? When an entire patient census is replaced in a matter of days and a series of hurried admissions? Someone stands to gain from this kind of system, and I would argue it is not the resident. Recently, a favorite attending of mine, teasing us about the abundance of specialized tests available to us, said half-jokingly that during her training a sleep study consisted of a resident spending the night at a patient’s bedside with a notebook and watching him sleep.
I think about this often, irrationally nostalgic for an era that missed me by decades — an era in which the hours were more numerous but less chaotic, and the time for study and reflection a certainty rather than a luxury. Things were not perfect, I know, but at least back then the hospital’s priorities — chief among them its commitment to residents — seemed to be in order.
Eric Beam is an internal medicine resident who blogs at the Long White Coat.
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