Internship, Residency, and the Coming Demand for Change

INTERNSHIP, RESIDENCY, AND THE COMING DEMAND FOR CHANGE FITZHUGH MULLAN, M.D.* Therehas been a growing debate over thepast years about the nature of medical education. The arguments have focused on die medical school and the necessity for upgrading and updating medical education. The Flexner Report,1 any ioo critics have said, was a great document in its time, butwe are due now for another overhaul in medicaleducation equal inmagnitude to that recommended by Flexner. Many recent programs, positions, and analyseshavepretendedtobe"TheNewFlexnerReport.''Significandy,they all have addressed themselves to medical school education, and none has alluded to house officership—"postgraduate medical education"—as an area ofattention. Indeed, the amount ofdebate, concern, and introspection that house officership has generated in recent years is minimal. In an effort to augment the desultory discussion ofwhathouse officership is and should be, I offer one resident's view ofwhat he sees around him. In 1910, when Abraham Flexner made his report, internships and residencies hardly existed. Medical schools, such as they were, trained doctors who ventured forth immediately upon graduation to practice their trade. The ensuing years saw the steady accumulation ofmedical knowledge and its rationalization and organization into more and more well-defined areas. Specialization and the brute increase in information demanded greater training. Thus postgraduate medical education ceased to be a rarity and became not only customary but the law (forty-six states require internship to practice medicine). The concept ofhouse officership was never well defined but tended to grow as the specialties demanded. The notion of education and training was never clearly separated from assumed responsibility for patient care * 140 "West 87th Street, New York, New York 10024. 1 Medical Education in the United States and Canada, 1910. 502 Fitzhugh Mullan · Internship and Residency Perspectives in Biology and Medicine · Summer 1970 and hospital staffing. Like other students, house officers were not paid. But, unlike other students, their lives were filled with frenetic activity and were void oftime for prolonged reading, study in depth, or contemplation . Learning, for the most part, came from overwhelming exposure— days and nights, seven each week. Traditionally, the role ofthe intern and resident in the medical life that inundated him was passive. He accepted his position as penniless errand boy ofthe system and concentrated on getting what knowledge he could from die experience. Indeed "training" (rarely called education) became the be-all for him because he could take little else away with him. There were, to be sure, other aspects of the house officership years: teaching (other house officers and medical students), community service, and personal physicianship, not to say breadwinning, marriage, and fatherhood. But all ofthese stood pale beside the mighty god, Training. Interns and residents were long expected to be unmarried and to live in the hospital. No one outdid the famed Harvey Cushing whose cult of neurosurgical trainees remained always celibate and took call year in and year out. In the present era of criticism, change, and unrest, house officership stands quiescent. Undoubtedly this is due in part to the fact that challenge and changearecomingprimarilyfrom the youdi ofthecountry who have not as yet reached the age ofinternship or residency. Pardy, however, this is due to the essential nature of house officership that I have outlined. Despite the hours, the working conditions, and the previously miserable pay scale, internship-residency is a time of self-aggrandizement. It has been a time for seeing "good pathology," "doing good cases," and testing as many skills as possible. Looked at from the outside, the years following medical school constitute a period ofsocial lassitude. While the peers ofinterns and residents become active in business, in the community, and in socially related enterprises , the house officer is in the hospital stoking himself with medical experience and skills. House officershave rarelyundertaken anycommunal responsibility. Even their hospital-based patient-care efforts are characterized by transiency and the dispassion ofepisodic medicine. In their rotation from service to service, house officers treat disease entities. They gain and lose patients with impunity as diey pass from subspecialty to subspecialty writing their "on-" and "off-service notes." In no residency do they have responsibility for long-term family care. 503 The social lassitude that house officership has...