For many generations, doctors seemingly had little choice. Work came first. Doctors were expected to live and breathe medicine, spend long hours at the office or hospital, and, when necessary, neglect their families for the sake of their patients.
Given the highly scientific and technical nature of medical practice, it is tempting to assume that the system of residency training developed in response to intellectual forces within medicine. There is much truth to this. After all, the need to learn scientific concepts and principles, to develop skills of critical reasoning, to acquire the capacity to manage uncertainty, to master technical procedures, and to learn how to assume responsibility for patient care all reflected powerful professional demands.
It is axiomatic in medical education that an individual is not a mature physician until having learned to assume full responsibility for the care of patients. Thus, the defining educational principle of residency training is that house officers should assume the responsibility for the management of patients.
A middle-aged man was recently admitted to a Midwest hospital for “refractory congestive heart failure.” He had been followed in the hospital’s out-patient clinic for two years with that diagnosis. Yet, he continued to retain fluid and gain weight, despite optimal treatment for congestive heart failure.
Considerable variation in quality exists among residency programs in the United States, even among those in the same specialty, such as surgery, pediatrics, or internal medicine. Some are nationally and internationally renowned, others are known regionally, and still others are known only locally.
The country has long had too many specialists and subspecialists, so the common wisdom holds. And, the common wisdom continues, the fault lies with the residency system, which overemphasizes specialty medicine and devalues primary care, in flagrant disregard of the nation’s needs.
Interns and residents have always worked long hours in hospitals, and there has always been much to admire about this. Beyond the educational benefits that accrue from observing the natural history of disease and therapy, long hours help instill a sense of commitment to the patient. House officers learn that becoming a doctor means learning to meet the needs of others.
Residency training has always had — and always will have — a dual mission: ensuring the safety of patients treated today by doctors-in-training, and ensuring the safety of patients treated in the future by current trainees once they have entered independent practice.
America’s system of residency training — the multi-year period of intensive clinical study physicians undergo after medical school and before independent practice — has dual roots. It arose in part from the revolution in scientific medicine in the late nineteenth century and the infatuation of American educators of the period with the ideal of the German university.