Through thousands of cases, physicians in training learn to be ready for anything
Late this spring, nearly 20,000 students across the country will graduate from medical school. Diplomas in hand, they will have earned the right to be called “doctor.” But on the pathway to becoming a practicing physician, being awarded your M.D. makes you a doctor in the way turning 18 makes you an adult: You’ve reached an important milestone, yes, but your journey is far from over.
For the vast majority of these medical school graduates, only a few weeks will elapse before they resume their education, as residents training in academic settings like the University of Virginia School of Medicine’s Graduate Medical Education program. They will spend the next three, five, seven or even more grueling years building the knowledge, the wisdom and the experience to prepare them for the practice of medicine. It’s an apprenticeship in complexities and subtleties, in the mundane and the life-and-death, in countless details amassed hour by day by week by year, in taking the extraordinary responsibility for someone’s health and well-being and making it the ordinary business of your everyday life.
And in a busy place like the University of Virginia Medical Center, that apprenticeship—particularly for first-year residents—is something akin to “drinking from a fire hose,” says Diane Farineau, director of the Graduate Medical Education office, which oversees the residency program. Under the watch of senior residents and attending physicians (doctors who have completed their training), gradually ceded increasing responsibility only as their expertise grows, residents are placed front and center in patient care from their first days on the job.
“It is a fairly steep learning curve,” says Kevin Greer (Res ’17), a third-year resident in anesthesiology. “Medical school prepared me pretty well for the transition, but the responsibilities of being a resident are so different from those of being a med student.”
“There is no more ‘I’m just a student,’” agrees Katie Blackard (Col ’11, Med ’15, Res ’18), a first-year pediatrics resident. “You are a doctor now, and your decisions matter.”
A world unto itself
To enter into the life of a medical resident is to surrender to a world apart. The days can stretch from before dawn to well into the evening. The weeks whir past in rotations through subspecialties and medical-care units: pediatric intensive care or surgical oncology or ambulatory anesthesia, the newborn nursery, outpatient surgery, labor and delivery. At the University Medical Center, “night call,” an on-call weekend or a weather emergency, like this past January’s blizzard, can find you bivouacked in the basement warren of no-frills, windowless dormitory rooms known as the “call suite.” First-year residents, often called interns, can field 40 to 50 calls on their pagers every day on duty, because “you’re the first-line person to talk to about a patient,” explains Alex Michaels (Med ’13, Res ’18), a third-year surgery resident.
You master the medical center’s geography, floors and units and the skeleton of stairwells you clatter up and down, heedless of the inspirational quotes displayed on walls you’ll pass one hundred, one thousand, too many times to count. You acquire an insider language of acronyms and abbreviations and specialty terminology, and share shop talk while clustered waiting for the elevator or over brief, blissful cups of coffee grabbed in the cafeteria (the hospital coffee kiosk, Farineau says, is “the epicenter of our universe”). You learn to plan your life with the precision of a military campaign, vacations plotted out a year in advance, weddings and babies slotted carefully into a yearslong commitment that, for some residents, can stretch well into their 30s with postresidency fellowships for additional training and specialization. And if residency is no longer the sleep-deprived ordeal it once infamously was—there are now limits on the hours residents can work—residents in some specialties nevertheless can put in 80-hour weeks on certain rotations.
“The hours are really, really long, and there are many days when you leave when you are absolutely exhausted,” Blackard says. Yet despite the hours and the pace, residents are quick to speak as well of the rewards. “I absolutely love what I do,” Michaels says. “There is nothing I would rather be doing.”
A purposeful education
There is no typical day for a resident. Your schedule depends on what year of your residency you are in, what rotation you are completing, what shift you are on, what specialty you are pursuing. With each year, too, residents gain more responsibility and independence as they demonstrate growing confidence and ability. “It comes slowly and purposefully,” Farineau says. “You are not taking out someone’s kidney in your first year.”
“It’s a progression from watching, to having someone help you do it, to having someone watch you do it, to having them be OK with you using your own clinical judgment,” Michaels says.
For an inpatient-ward rotation, working with pediatric patients, first-year resident Blackard describes shifts that begin in the dark, hours before dawn.
“I come in on this rotation anywhere from 5:30 to 6 a.m., depending on how many patients I have,” she says. “I go through all their charts and check their numbers and vital signs and labs, talk with the nurses about what happened overnight, and then I go see all my patients and check in with them. Then we do rounds, which can last two, three, four, five hours.”
“Rounding,” a common feature in many residents’ days, serves an important role both in resident education and in patient care. It’s an opportunity for a treatment team—residents, attending physicians and others—to assess the patient’s status and plan of care. “We do family-centered rounds,” Blackard explains, “where we walk around to every room and ask the family how they would like to participate—to have the entire team come in the room or for the family come out and talk with us. We emphasize that parents are part of the treatment team, and kids are, too, if they are old enough.”
After rounds, residents complete all the patient care for the day, from calling in specialist consultations to ordering medications and laboratory or imaging tests, to setting up follow-up appointments for patients being discharged. Interspersed with patient care are morning conference and noon conference, when “we have lectures by faculty about certain topics,” Blackard says. Finally, at the end of the day, “we sign out to the night team, going through all the patients and their plans for the night, and ‘if this happens then do that.’ And the next day the night team signs out to the day team and it starts all over.”
For surgery resident Michaels, a similarly long day would lead from early-morning rounds to the operating room, where he might be part of a team tackling one or two major surgeries or five or six more-routine procedures like hernia repair and gallbladder removal. Then there are clinic days with pre- and postoperative patients, everyone from the weekend warrior with the ACL tear to the grandmother with the heart-valve repair.
“A lot of people who have seen a TV show get the idea that every stage of the way is glamorous, but really a lot of it isn’t,” Michaels says. “There’s a lot of doing paperwork and other mundane things.”
Yet there are also rotations through the emergency department and intensive care unit, where a shift might see trauma patients from car accidents, falls, gunshots, burns. On the first day of his second year of residency, Michaels was assigned to the trauma ICU, and a young man was simply “dropped off” in front of the emergency department with a gunshot wound to the chest, and a fiercely focused team effort unfolded to try to save his life. “As general surgeons, we are learning to be ready for anything,” he says.
Being “ready for anything” is in fact the whole point of the intense, demanding residency years. No trial by fire merely to test residents’ determination and fortitude, residency exposes physicians in training both to constant reinforcement of the routine and to the widest possible range of the unpredictable, the unexpectedly complicated, the split-second decision. Michaels says he’ll expect to have seen something like 1,000 surgical cases by the end of his residency. “We need to do so many cases in our training so that we feel comfortable with all the different iterations we may run into. There are ‘textbook’ cases that are really straightforward, but almost every case has something different or unique, and you need to do a ton of cases so you can recognize what’s normal and what’s abnormal.”
“All cases present their own challenges, and all scenarios do,” agrees Greer, the anesthesiology resident. “As you progress, your responsibilities change and the way you look at things changes as well. Med school gives you a great background, but residency is going from all this information you learned and textbooks you read and tests you took and putting that knowledge into learning how to help the patient.”