New interns — doctors who have completed four years of medical school — often don’t order the right treatments for common medical problems. New interns specializing in emergency medicine often aren’t able to place an intravenous line, let alone manage a cardiac arrest on their own. During their first weeks on the job, or sometimes months, interns need another doctor to monitor every single order for lab testing, imaging, and medications.
Yet that’s what I see as the senior emergency medicine resident supervising new interns at two Harvard-affiliated hospitals, Brigham and Women’s Hospital and Massachusetts General Hospital. Interns are especially prone to making medication errors. This problem isn’t specific to Harvard-affiliated hospitals; it spans academic hospitals across the country.
I worry about these deficits. You should, too, especially if you find yourself in a teaching hospital in July, when interns begin to work.
These observations of mine feed into the longstanding question of whether a cause-effect relationship exists between new interns and in-hospital deaths. According to the National Bureau of Economic Research, adjusted mortality within teaching hospitals rises 4 percent in July, the month interns first descend on wards and emergency departments. A 2010 University of California, San Diego, study went further and found a 10 percent rise in fatal medication errors in July in counties with teaching hospitals; no spike was seen in counties that did not have teaching hospitals.
I’ve begun asking interns I work with from multiple specialties — internal medicine, anesthesia, emergency medicine, and orthopedics — who rotate through the emergency department if and why they feel unprepared during their first week of residency. The most common answer was some form of this:
“I feel underprepared mostly because I have never had to put in computer orders by myself before” for things like laboratory tests, imaging, and medications.
I certainly know the feeling. It’s how I and most other new doctors felt on day one of our intern year.
The short explanation for why interns have difficulty selecting orders — and thus managing their patients — is that they had limited opportunities in medical school for active engagement in patient care, including working side by side with experienced physicians to understand why they selected particular tests and treatments.
The importance of having medical students work closely with seasoned physicians lies largely in the opportunity for discussion about why certain tests and treatments are ordered. This process is essential for learning because it helps build cognitive links for students between the varied clinical presentations (the combination of a patient’s medical history; vital signs like heart rate and respiration rate; and the physical exam) and suitable testing and management. Without this process in medical school, senior residents like myself are left walking interns through ordering nearly every test and treatment.
Without sufficient experience placing orders during medical school, interns are able to apply rote knowledge, like a medication name, but will be deficient in important details of clinical decision-making, such as dosing and identifying the severity of an illness. For example, interns know that albuterol is the treatment for a flare-up of asthma, but they might not know the proper dose, or that adding steroids is appropriate when the patient’s lungs sound particularly tight and wheezy.
Requiring medical students to be more engaged with their supervisors while placing orders will undoubtedly improve interns’ clinical effectiveness when it comes time for them to begin placing orders for blood tests and medications.
Another solution to improving intern preparedness is to incorporate “boot camps” in medical school during the spring before starting internships in July. In these boot camps medical students can practice the skills most pertinent to their upcoming residency or specialty training.
The work for creating boot camp curricula has already been done by various institutions, and can be adapted for broader use. For example, the Harvard Affiliated Emergency Medicine Residency has a boot camp for interns that teaches skills such as how to place ultrasound-guided intravenous lines and managing mock cardiac arrests and medical resuscitations. Another improvement could be a crash course in monitored bedside manner training and breaking bad news to patients and their family members.
According to Dr. Christa Zehle, the associate dean for students at the University of Vermont College of Medicine (where I went to medical school), such boot camps should not only be placed earlier in the medical training timeline, specifically during medical school, but there is the potential to standardize care delivered by interns by incorporating them into what the Association of American Medical Colleges calls the core entrustable professional activities , which are essentially the requirements for beginning a residency program.
Although naysayers will point out that these solutions are a burden on supervisors, either residents or attending physicians, or that it merely shifts intern year into medical school, it is certainly a safer alternative than having new physicians who feel uncomfortable independently placing an order. It is also more sensible than one doctor reviewing every order by another doctor, which is what I and senior residents across the country do during the month of July, sometimes for five or six interns at a time.
Improving medical school training in these areas has implications beyond better patient care, including positive effects on interns’ mental health and wellbeing. Constantly being questioned by supervisors makes an already emotionally taxing experience — dealing with life-and-death situations while sleep deprived from intense work hours — much worse.
Interns should be coming to work with clinical competencies that fill them with immense pride. And while they eventually establish this workplace confidence, it should come much earlier, during medical school, not after they have added the title M.D. to their names.
Christopher L. Taicher, M.D., is a fourth-year emergency medicine resident in the Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital and Brigham and Women’s Hospital. He is also the founder of Rezolve, a telemedicine startup.
We have allowed the university systems and the “accrediting bodies” to regulate what SHOULD have been the doctor-patient function from day one. Going back far enough one would see that doctors were anyone who was ballsie enough to call himself out as one then as things “progressed” some bad apples spoiled it for the majority of docs who actually tried their best day in and out to do a good service for society.
Now we have EVERY action under a microscope viewed NOT by US but by people looking to point a finger and say “see I told you that given a potential to make fire docs will”
The university systems should NEVER have been gifted with the control of the process. I would LOVE to see a comparison of the current university trained doc and Dr. Taicher’s apprentice enabled approach.
Since I was in college (I started out as a double major engineering and business) I thought about what medical would look like if 100% of our attention was focused on working with a team of existing docs to learn from them what they know and what they do on a day 2-day basis.
I can EASILY see the entire medical school and college process melted down to 2 years of sciences mostly anatomy,y histology pathology and the like and then off to the apprenticeship stage for another 10 years
All in all less time than the current mess and FAR less costly and assuredly a better hands-on doc.
Admittedly not as well capable of passing electronic exams and or other standardized yuck but I bet they would be ideal to provide better care at a FAR less costly outcome. Let’s be realistic most of what we DO is simply a result of the way we were taught it and that is all based on standardization and regulation.
Why do we all need to be rote robots of each other? Why can’t some be better and or worse than others and why can’t the market be fluid so that patients seek care based on needs and not under the assumption that everyone is equal so go where the InsCo dictates?
Kudos to Chris for broaching the idea now how do we make it a reality?? 🙂 🙂
Dr. Dave
Who is #DrDave #solidcomments
To elaborate a bit on my reply to Dr. Wenker, I was not suggesting that it is a lack of medical student interest nor a pure problem of what students are allowed to do.
Part of my article discusses how the environment and curricula don’t facilitate sufficient hands on experience in areas that matter most, like placing orders.
Further, even if credentialing bodies never allow medical students to do things like place a central line it does not mean we can’t better prepare them through closer interactions with physicians on shift.
For example, with regard to central lines….an alternative is to have medical students more frequently practice on mannequins in simulation labs, and also have them assist physicians during patient procedures. Though it may not confer the same degree of procedural competence these suggestions could improve residency preparedness.
I have always felt a stint through Nurses training, Medical Laboratory Scientist training, Radiology training and Nutritionist training would give us a better physician. Certainly, an accelerated version would be necessary. Learning and doing in a day, what all these professionals do behind the scenes” is a far more comprehensive training. The win-win would also be the sharing of knowledge between the aspiring physician and those providing this hands-on experience.
I am a practicing Emergency Physician, trained in the 90s, and finished residency in 2001. As a med student, I did CPR, central lines, LPs, and even IVs. I trained in the time of written orders, and I’d do the entire order set for Burn ICU patients while on my plastics rotation as a 3rd year student. The fellow would add or change a few things, but generally not much. The problem *isn’t* that med students are unwilling when it comes to being prepared for internship; it’s that they’ve been pushed away by credentialing bodies who make it difficult for medical students to do their own assessments or do any charting. Fourth year med students who rotate through my community ED essentially shadow us. They don’t write any histories, do their own exams, or enter orders in the EHR. Why? Because they aren’t allowed to. Take it up with credentialing bodies who created this disaster.
Chris
Splendidly spoken sir!!! (based on this you will be a superb ED doc)
For 30++ years I have complained that we waste the 4 years of medical school by teaching crap that any monkey can look up in a reference guide (or now on an iPhone) and not the real world of “use it everyday” knowledge
Knowing the molecular attachment for the 3rd carbon in the chain is useless but we CAN teach the things you suggested at ANY point in the curriculum since it takes NO previous understanding
Things like IV access and triage positions and BCLS are all teachable even as far back as the 1st year. Waiting till the Internship and or residency to teach this pushes the reality of clinical life further down the pipeline and into the position where any error really affects a human patient and not some mannequin or teaching aid.
There is NO reason why the use of the computer EMR and HOW to order tests and drug products couldn’t be done in 3rd-year medical school or at worst 4th
I have trained more fellows/residents then I care to think about and you are spot on. All were as dumb as rocks in the important things of clinical life but all could describe the Krebb’s Cycle in immaculate detail as if that was going to save a patient.
The “Monster July” date is not unique to teaching hospitals it is also the date that residents are released on the community at large to exercise their state given right to cause harm on their own license. I am SO sick of the rookie grads showing up with notions of grandeur who all of a sudden find every patient needs that ECRP or CABG or Thyroid uptake study because they see tuition bills coming due and are looking to impress their new employer that they can produce to justify their salary.
You are spot on we need to back up the important stuff to earlier years and then reinforce them thru the medical school days so when we let them loose they are not deer in the headlights on REAL humans expecting quality care and not realizing that their “doctor” is more green then the nurses aid who is changing the bed linen
Dr. Dave
Well said! I finished med school in 1973, my son finishes in 2019. I wrote orders which were counter-signed or cancelled, but I wrote them. I lived in a world of “see one, do one, teach one,” and learned by doing. The current trend is to shift medical school into the intern year – but interns can write orders which need no review and God help the patients. My son pays tuition 20 times what I did per year and gets a far worse education.
Thank you Drs. Dave, Feinberg, Wenker and also Carol for your thoughtful replies. For simplicity I put my reply in one text.
Dr. Dave I couldn’t agree more about the nurse being more seasoned on day one than the intern. I will never forget a nurse throwing me a BVM and asking me “if I was gonna start bagging him through his traech”.
Dr Feinberg, thank you for your forty-five years of service in the field. There is an immense fund of knowledge you could teach us and hope you keep speaking on the subject. I wonder how things would be if we moved towards more of an apprenticeship model for teaching medical students.
Dr. Wenker, I was not suggesting that it is a lack of medical student interest. Part of my article discusses how the environment and curricula don’t facilitate sufficient hands on experience, much like you obtained when you placed central lines as a medical student.