On the Backs of Residents

I am privileged to work with residents who are smarter than I am.  I have seen the step scores, the in-training exam results; my learners would have crushed my class rank back in the day.  So as an educator, I strive to be that shoulder to stand on, by sharpening their diagnostic skills, taking the rough edges off their bedside manner and imparting the know-how of Doing The Job I’ve gained along the way.  Because I know they will see farther than I ever will. 

I wish that could be the narrative that’s on my mind tonight, one of elevation and achievement.  But I keep going back to my daughter’s bedtime request – Yertle the Turtle, the story of that pompous king of Sal-Ma-Sond.  The doomed king of all he sees – achieving such great heights by standing on the backs of those beneath him, but still calling for more, more, more.

I keep scrolling back in my phone to this photo of my chief, taken at the end of 14 grueling hours. I see his shoulders heavy with fatigue, recognize the invisible burden of everything we had asked of him up to this point.  (Which he, and all my chiefs bore with grace and determination far beyond their years, often surpassing those in positions senior to them.)

Lately, I had adopted the title of “COVID problem fixer” when introducing myself to new-to-us faculty, in that yes, it WAS my job to make sure everyone had (and was wearing) their PPE, push out updated information on consensus best practice amongst our specialists, arrange meeting spaces, make sure folks had admitting privileges in our EMR, work assignments were sent out to the floors, and that each patient had a resident team to oversee their care.   It made sense that someone in my position would do the job – early faculty, connected with the residents but able to talk with the Powers-that-Be and translate what each side needed.

I joke that my current position in Scrubs terms is “Elliott who turned into Dr. Cox and figuring out if Dr. Kelso is in my future”

But the more I stood back and looked at the big picture, the one developing in hospital after hospital, I saw the true “Problem Fixers” to be the same folks it always has been.

Residents at safety net, large scale teaching hospitals.  That’s who the show is about, after all. The ones whose backs hospitals stand on.

Code Blue Running, 2 AM admission completing, page-answering, sub-specialty staffing and family updating residents.  J1 and H1 visa holding residents especially, when you consider the hospitals hit hardest by this pandemic.  Indebted young doctors who have pledged their years of service in exchange for the teaching and practice they need to transform into effective, independent physicians, hopefully climbing up the scaffolding provided to them by seasoned veterans of the field.

True, it’s not as bad as it used to be.   “Residency” is no longer a seizure risk factor, due to the endless sleep deprivation of spending 8+ months of the year doing 30 hour shifts every 4, or even 3 days.  

But part of spending that many of your years sleep deprived is similar to the memories parents experience – those precious newborn years collapse into a baby-powdered scented haze of the good while the bad fades away.   All the snuggles, none of the projectile bodily fluids. And so attendings, administration – people who aren’t so far removed from their own resident years tend to forget what the slog does to idealistic young doctors.

Having all of the accountability and none of the authority.  Your only response to “Jump” is “When, and how high?”  Minimal control over your schedule, either hour to hour or month to month.  (Turns out my shoulders aren’t just for standing on – so many have leaned or cried on them when the ability to cope runs out and the burnout sets in).  The knowledge that this is not a job that you can turn your notice in, not when you know that your work is going to get reassigned to your peers when you bow out, or when the safety and security of your family depends on your immigration status. 

One thing that made Scrubs great was the lack of true villains. The chair of medicine was made out to be a bad guy, until you realized that he was once the main character. That he too, was trying to do his best for his people and the patients, but so frequently lost touch with the day-to-day reality.

So I implore the people making decisions on what problems resident services can handle to spend a day actually doing the job again.  Hold the admissions phone overnight.  Run from one rapid response to another. (Try doing it in an N95 mask.) Do a discharge medication reconciliation.  Take trauma call.  

If you can’t see the faces and hear the stories, then you can’t possibly understand What is being sacrificed when faceless entities call for “More, more, more!”

The thing I will be grateful for, through all of this – my institution will be on the right side of history. We asserted that residents would NOT be first line, as so many other organizations have.  We ensured them max available protective equipment and empowered them to wear it all the time, trying to match the latest information on infectious burdens to what we had on hand.  They may have been our problem fixers, but we kept them safe.  We didn’t use the excuse of their youth and health to justify an undue share of the risk, knowing they didn’t have the luxury of opting out. We recognized the weight of seeing the isolated, sick and dying each day – giving days off and shortening shifts whenever we could, trying to give them a chance to catch a breath before the service swallowed them again.

The hope I have coming from this in the future, is the burden placed on these proverbial turtles at the bottoms of such prestigious and profitable stacks becomes evident.  I wouldn’t wish for any healthcare system to topple into the mud, much less ours come July 1st. Trust when I say that our hospitals do not function without our PGY classes.  We need them here and secure in our steadfast support; visas in hand, ready to work, learn and see us through the next set of problems.    

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