Medical education's dirtiest secret - use of medical residents

Nearly one hundred thousand patient deaths per year are attributed to provider error, according to a November 1999 report by the Institute of Medicine of the National Academies. Overwork and exhaustion are sources of such errors. And among all doctors, the most overworked are medical residents--medical school graduates employed by teaching hospitals ostensibly to receive training in a medical specialty but, practically speaking, to be utilized as cheap labor.

According to Jung v. Association of American Medical Colleges, a May 2002 lawsuit filed in a Washington, D.C., federal district court that challenges the residency employment system, typical medical resident work hours range from 60 to 136 per week. The starting hourly compensation rate calculates out at about $10 per hour on average. And the vast majority of U.S. medical residents aren't represented by labor unions.

Currently the New Jersey state legislature is considering limiting resident working hours. The only state which has already enacted such legislation is New York, in response to the 1984 death in New York Hospital of teenager Libby Zion, which occurred when an overworked resident declined to come to her bedside.

Since the fall of 2001, two members of Congress, Representative John Conyers (Democrat, Michigan) and Senator Jon Corzine (Democrat, New Jersey)--concerned about the threat to patient safety posed by overworked, overwhelmed, and exploited doctors' delivery of inpatient care at the nation's four hundred teaching hospitals--have introduced bills to impose a limit of eighty work hours per week for the approximately ten thousand residents. Though both initiatives are currently before committees, it could be years before the proposed legislation is adopted, if ever.

Furthermore, these efforts, laudable as far as they go, don't address many ugly abuses In medical education. Aside from exploitation of residents through failure to enforce reasonable working hours, the ugliest feature of medical education is the draconian methods that medical educators use in disciplining residents. Medical school administrators have been functionally free to resort to actionable or illegal acts such as defamation or physical mistreatment. The latter can include increasing the trainee's workload, denying leave for illness and even corporal punishment.

In my experience as a medical resident, I have observed these abuses in action. Denial of sick leave (especially extended sick leave), for example, is common. The standard rationale is that if leave were given the duties of the absent resident would become the burden of his or her peers. Indeed, I was denied sick leave more than once; on one occasion I was ordered to continue serving at the local children's hospital even after my personal physician had informed the residency program secretary that I was suffering from both strep pharyngitis and infectious mononucleosis.

Hospital administrators engage in abusive discipline because they can. The perpetrators must account to no one and nothing in the typical contract signed by a doctor joining a medical residency places limits on her or his superiors' disciplinary prerogatives. Yet such practices take place under a veil of secrecy. Those who perpetrate them depend on the intimidated silence of the victims who, after years of expensive medical school training, are afraid to risk reprisal by complaining. Abusive discipline thus thrives not only on the arrogance of the powerful but on the shame and fear of the powerless.

In the shadowy disciplinary armamentarium of medical education, the dirtiest secret is disciplinary psychiatry. It exemplifies the medical community turning on its own. Disciplinary psychiatry can be defined as coerced subjection to psychiatric intervention as a condition of remaining in training. Medical educators use it not only against doctors in residency but also against medical students in the process of earning a medical degree.

The term disciplinary psychiatry refers not to a situation in which a person with an established diagnosis of mental illness is enrolled for medical training but to one in which the medical education administrators seek to establish a diagnosis of mental illness in a trainee by forcing him or her to see a mental therapist of the institution's own choosing.

Disciplinary psychiatry likewise doesn't apply in the event that, after embarking on a course of medical training, an individual voluntarily chooses to undergo therapy with a psychiatrist or psychologist--which the supervisors happen to learn of. Disciplinary psychiatry applies, rather, to a case in which, under threat of removal from the program, an unwilling trainee is forced into treatment by a therapist chosen by her or his supervisors, with the added requirement that the supervisors can learn of the diagnosis and monitor the trainee's progress in therapy through reports provided by that therapist. In other words, it is disciplinary psychiatry when the trainee must forgo confidentiality, both as regards to the choice of therapist and the content of therapy.