The difference between medical practice and medical training

I have never experienced a military boot camp.  I have however completed a rather intense three-year residency in internal medicine followed by another grueling, three-year fellowship in pulmonary and critical care medicine.  I like to think that my experiences were not unlike those of military training.

As a matter of fact, being on the medical wards at the county hospital was referred to as being, “in the trenches.”  It was true.  We were literally on the “front lines” with our duties as internal medicine residents including everything from triage in the emergency department (admitting officer on duty) to running code blues for every other service in the hospital. We were typically on call with one or two interns, one senior resident and one or two medical students.  That was your firing squad for a month-long rotation.

I started my residency shortly after the maximum 80-hour work week rule was put in place for medical trainees so we were spared somewhat but that didn’t mean that we always abided by work hour rules and even take pride in breaking them from time to time.  There was a sense of ownership among our little medical squads and every member of the team believed that nobody could take care of our patients the way that we did so we never left a job unfinished.  We developed bonds with one another and we learned from each other as we developed confidence in ourselves, each of us being integral to our small unit.

Often in times of battle, your team would be called to help another.  I remember one night on call as the senior resident in the intensive care unit.  The obstetrics department was also known for having, competent, respected residents who took pride in caring for their patients until they absolutely could not.  One of the OB residents called the ICU pager and when I answered the call she said, “Thank God it’s you on call tonight Dr. Stream.  We need your help.” I didn’t know what they needed but just her response to hearing my voice made me confident that I could help.  I rallied my troops and we went in.  That was how it worked.  We didn’t think about how long the job would take or how we would bill for it.  That is not something that is taught in residency.

Fast forward to my first experience as a moonlighter during fellowship taking weekend call for a private practice.  I was given a list of 24 ICU patients to see (which is very minimal for most practices) while fielding new consults and given instructions to document my “critical care time” on each patient for billing purposes.  My shift seemed to drag on as I got calls from nurses telling me their patient’s doctor said to consult critical care.  I was it.  There was no team to rally and no particular concern on behalf of the consulting physician about speaking with me directly because he or she was busy being a one-man-army somewhere else.

At the end of the day, I felt less like a soldier as I tried to decide whether or not the end-of-life discussion I had with a patient counted as “critical care time” and while mourning the death of my medical firing squad, I wondered if I had lost the battle as well.

Amanda Stream is a pulmonary and critical care physician.

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  • PoliticallyIncorrectMD

    Agree 100%. From my own experience critical care and private practice don’t mix. The likely reason is that most of the private practices are based on profit / loss model and critical care is not exactly a money maker. Unless the whole healthcare delivery system changes, those who went into the specialty for the right reasons will be bound to work for large academic centers or find like minded colleagues to form a practice which prioritizes patients’ care over monetary gain.

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