Intern at Harvard Medical School: 100 hours of intensive training per week, working at four in the morning

Author: Yang Yuanfan, Source: Transferred from Yang Yuanfan Science Network blog

A few years ago, I participated in a medical student exchange internship program at Harvard Medical School.

During my short two months in Boston, I experienced intense training in neurosurgery, 100 hours a week, and established cooperation and friendship with my American counterparts, Concordia alumni, and exchange students in Taiwan. Two months of life, full of energy, not even free weekends, but brought me countless good memories.

Our clocks are different from normal people!

We are on a different cycle！

Before going to Harvard Medical School, I worked as a trainee physician in the Department of Neurosurgery at the University of California, San Diego (UCSD), and I already knew a lot about the working hours of surgeons in the United States, so when I first arrived, I was mentally prepared for more than 100 hours of work per week.

In the United States, neurosurgery is the most attractive specialty in the field of surgery, the work is highly technical, the highest challenge, the sense of achievement is large, and the income is much higher than that of other specialties, so every year when admitting residents, these people have different abilities and characteristics, but a most basic common point is willing to undertake long-term, high-intensity daily work.

When I was at the University of California, San Diego (UCSD), we medical students basically got up at 3:30am every day, went out at 3:45AM after breakfast (hitchhiking with local medical students), arrived at the hospital before 4:00AM, started pre-Round, prepared information about patients in the whole ward before the 4:30AM morning rounds, including vital signs at night, status of consciousness, intake and drainage, intravenous fluids and medications, As well as the basic electrolyte situation (most of them are recorded by the ICU nurses, do not need to measure themselves, just need to fill in the early rounds of the table, and report them in English during the rounds).

There were no classmates in Boston who could take my free ride, so I had to take the first bus at four o'clock in the morning, so that by the time I got to massachusetts General Hospital (MGH), the resident doctor would have finished writing his medical records. Because I went out early in the morning, I could only go home in the evening to rest quickly (when I first went, I added jet lag, I didn't even eat dinner twice, and I fell asleep tired without taking off my coat, which was a profound experience!). The working day will generally rest before 10 o'clock on time to ensure the mental state of the next day's work, and the life of a surgical resident is like this, clear and self-disciplined.

At 4 o'clock in the morning, on the road, seven or eight out of ten are doctors, and the rest are medical students, even if it is such a snowy day, walking on the road can know a lot of MGH colleagues.

In hospitals, superior physicians often talk to us about "If you are in the lowest rank of the team, you should be the first to know everything happened." This means: as a small doctor, you must be diligent and have a correct attitude in the team, if you do not understand the situation of the patient and wait for the superior doctor to tell you, you will be embarrassed.

Of course, there are also many students who are interested in doing other related fields, such as anesthesia outside the gods, if they rotate outside the gods, they can consult with the director of the Department of Education of Neurosurgery on the first day, and they do not necessarily need to participate in the early rounds, and the time saved the teacher may arrange to do some literature reading, literature reporting, etc., or the requirements for neuroelectrophysiological monitoring will be higher.

In short, all reasonable requirements can be negotiated, and the school encourages different people to do their best in different directions that they are interested in, so that more graduates can achieve a career, not all of them take the same path, only a few people receive more attention and are rewarded, and a lot of manpower and talents are actually wasted.

For me, my favorite direction is neurosurgery, naturally there is nothing to be picky about, basically keeping the same time as the resident, so every day to take the first bus in Boston morning (when I go out, the subway has not yet sent the first bus, I have to take the bus), and then change the subway twice to get to the hospital at the earliest. On the first bus at 4 o'clock in the morning, most of the people are surgeons or interns in the hospital, and almost all of them will get off after arriving at massachusetts general hospital, and many doctors are directly wearing brushing clothes on the road, so the bus is a light blue, this bus is also known as Boston Medical Train, which can meet the doctors and interns of various departments, and it is also interesting to talk about the day.

Doctors can be said to be the spokesmen for these beautiful words in American society such as "diligence", "erudition", "social responsibility" and so on, but a glance at the time paid by young American doctors shows that such respect is not easy to come by. Every time the patients lamented that the doctor had come early during the morning rounds, we used to laugh and say," "We are on a different cycle!"

Surgeons work overtime, but the Massachusetts General Hospital will give the doctors treatment and benefits are very good, no matter when the operation, the ward has milk, yogurt, bread, and when it is too late to eat, there are also enteral nutrients - "Ensure" (in fact, the domestic ansu, very difficult to drink, but very energetic and nutritious)

Surgical residency training is much greater than concord

When we were in China, we often took a little pride in front of outsiders because of the huge number of patients in the hospital, so we also formed some impressions, such as foreign doctors seeing few patients and leisurely, but this impression is very different from north America, especially in the stage of residency training.

During the neurosurgery internship at massachusetts general hospital, a different ward was rotated every week, but the patients in charge of each ward were only high and low senior with 2 residents, 1 intern doctor like me, and such a small team was actually responsible for 25-35 inpatients in the entire ward, which did not include 5-10 emergency patients in the observation room every day (of course, in the ICU, each patient has its own nurse, and will help a lot), to participate in all the operations in the ward. This is equivalent to the workload of the entire ward of Concordia, and this work is done in Beijing by about 7-8 residents plus 2-3 interns.

Therefore, although the total number of patients in Concordia is large, according to the number of doctors per capita in charge of beds, the per capita workload of surgical residents in massachusetts general hospital is about 4 times that of Concordia.

Part of this is cost control considerations, because the labor force of Doctors at Harvard is extremely expensive, and it is cheaper to hire 10 auxiliary personnel than 1 doctor, so the chores that will reduce efficiency will never be done by doctors, mainly by relatively low-paid assistants to help solve (for example, doctors write medical records and surgical records only need to say, there are specialized typists to help type, or use expensive voice recognition systems, but no matter how expensive they are, they are cheaper than doctors).

On the other hand, it is also conducive to the accumulation of experience in resident management of patients, and the amount of surgery involved per capita is also much larger, although it is hard, but it grows rapidly. In China, because the treatment of doctors and the auxiliary team of the hospital cannot reach such a rich level in the United States, it is difficult to demand that doctors pay such efforts and motivation as the United States, but the number of patients per capita is not large, the number of resident doctors involved in surgery is small, and the per capita exercise of surgery is insufficient, which is a fact that we do not want to admit.

Unlike in China, the attending physician does not participate in early rounds, and is primarily the responsibility of the resident physician. Two residents will see 25 patients in the whole ward plus 5-10 emergency rooms together, on average, each patient takes 3 minutes, and sometimes needs to answer the questions generated by the patients' own checks in the New England Medical Weekly, and the 30 patients add up to nearly 2 hours. This is why it is necessary to start rounds before 5:00 AM every morning, so that after checking on patients before 7:00 AM, while eating breakfast, they will report their own patient situation and doubts to the attending physician separately, and the first operation will generally start at 7:30 AM. The attending physician will take time during the day to see his patients and make some big decisions, rather than having everyone check together, which is very efficient.

When we were in Concordia, the director of surgery mentioned that there was a great waste of human resources, the time and ability of many young people were not fully utilized and utilized, and there were many spare time and equipment, which could have created greater clinical and scientific research value. Concord relies on enriching difficult cases in North China, which is conducive to the accumulation and growth of young physicians' experience, so we still retain some of our own advantages and characteristics, allowing physicians to have a relatively good work cycle at the same time, although it is harder than other industries, but it is very happy with the United States.

Every morning at 6:45 a.m., the city of Boston had just woken up, and the doctors were ready to start the day's surgery.

After the rounds, we went back to the office, where the resident reported the patient to the attending physician and made some decisions together, and the lady next to us was a nurse practitioner who would help us with all the transactional work without the doctor bothering.

The amount of surgery during the day is very large, and some attending physicians even have to arrange 6-7 surgeries, which requires a strong resident to assist in the completion of the main operation, and the attending physician is on the side to guide and teach. Without these experienced, hard-working residents, it would be impossible for them to complete such a large number of surgeries.

The night shift is completely unable to rest, not only to manage the ward, but also to continuously receive emergency specialist patients, because the Massachusetts General Hospital is the last line of referrals, can not push patients outward, so there are many acute and severe cases here. An average of 12-15 patients were admitted each night, most of whom had acute cerebral hemorrhage and trauma.

Miscellaneous Tastes: Understanding Concord in the United States

In the BWH's extra-theosotherapy room, what touched me the most was not Professor Al-Mefty, the giant of skull base surgery in the world, but lin ning, the chief hospitalist next to me.

This time, because of chance, I met Lin Ning, a Chinese doctor, in the operating room. He grew up in Beijing, went to the United States in high school, graduated from Duke University, entered Harvard Medical School, and is now a Neurosurgery Chief Resident at Harvard University's Brigham and Women's Hospital, nearing the completion of seven years of extratheordinary residency training. A friend has told me before that in the high-intensity, fast-paced field of neurosurgery in the United States, there are very few Chinese doctors, and Dr. Lin Ning must be the best in it, and his growth is a model of the American dream.

When I told him I was an exchange student from PUMC, he immediately spoke happily of his relationship with Concorde. It turned out that when he was a medical student at Harvard 8 years ago, he also came to the Concordia Exchange and rotated the neurosurgery department. During that period, he summarized the characteristics of pituitary surgery with neural navigation assistance and the experience of treating Mccune Albright syndrome, and under the guidance of Professor Wang Renzhi and Dr. Dou Wanchen, he wrote an article published in the Journal of Neurosurgery, which was a rare high-level English literature outside the gods at that time, and the teachers outside the Concorde gods still remember this "child" vividly.

Later, at the annual meeting of the American Association of Neurological Surgeons, I met Dr. Lin Ning as a reporter, and on the last night we sat down to talk until eleven o'clock, talking about the career and growth of extraordinarily residents. In fact, Concordia has a total number of difficult cases that are difficult to reach in the United States, but we do not cherish it as much as they do to carefully study and compare each specimen, and each patient does some follow-up and observation. For students, we rotate in Concord for a year, in fact, the English level is not bad, but rarely diving down to summarize the information, doing such work, but also lack of similar awareness and motivation. We often use some concord objective conditions as an excuse, such as too busy work, low salary, we prefer to see more patients, images and pathological data are not good to ... Wait, wait, and so on, and an American student in China in just one month, the user and our same conditions and environment, but can have such a job, can not help but say that we ourselves can not make good use of the resources of concord this century-old hospital, in other words, we are eating concord's old books without adding glory to her.

Everyone who comes to us, everything, is to teach us something, as long as we do not stay in the superficial, to think and explore, then communication brings us thinking and transformation, may be more than the knowledge itself. Sometimes just like the story described in "The Siege", we all look at the outside world and the unobtained things, look forward to that kind of life and work, but forget that there are actually people and environments around us that are not inferior or even better, but we have not opened our eyes and know how to cherish, until we go out to see how precious the things that were easy to have, but it came too easily, and even failed to understand its weight, which is also the immaturity of our so-called "good students". Seeing Dr. Lin Ning's work in Xiehe, I could feel a burst of fire on my face and a wisp of guilt in my heart.

When I was in Concordia, I did not have such a deep understanding of the meaning of the "treasure house" of Concord, and childishly believed that objective conditions limited our ability to think and summarize knowledge and do the best, but in the United States, understanding Concord from the experience of Harvard students let me know that what really limited us was our own thoughts and values, our self-confidence and courage, and better understanding Concordia on the other side of the ocean. I learned a lot from my interactions with Dr. Lin Ning, and he later gave me a lot of valuable advice, hoping that I would learn more in the next stage of neurosurgery residency and keep in touch with them.

Deepest feeling: We really don't have their efforts

When I mentioned Dr. Lin Ning to my mentor Professor Wang Renzhi, my mentor was full of praise and asked me to learn from this master brother who was 8 years higher than me. His upbringing was typical of the growth trajectory of a neurosurgery resident in the United States, attending the best universities, the best medical schools, being a resident in the best hospitals, rich clinical research experience, teaching positions in the Harvard Neuroanatomy Department, and of course, happy little homes and children. But behind all this, how much hard work, how many days and nights of struggle, can make him stand firm in this field of neurosurgery, which represents the crown jewel of medicine, and become a Chief Resident in this field where white people are absolutely strong, and will continue to do so.

Yes, the clinical tasks in Beijing are indeed very heavy, but here it is even more so, on the ACGME website, we can see that Dr. Lin Ning's 7 years of neurosurgery residency (of which the fifth and sixth years of rare surgery for scientific research training), as a first aid or main surgeon completed all the surgical records, a total of about 1900 units. The United States requires a qualified extratheoristic resident to complete more than 1500 surgeries during the 7-year training period to be able to successfully graduate, otherwise it will be postponed, if you want to apply for good sub-specialist training, such as functional neurosurgery, generally more than 1750 cases will have an advantage. When I showed these figures to Dr. Bao Xinjie, the chief duty officer, we were all sighing.

The ACGME resident case log system, a nationwide networked resident case registration system, records all the surgical conditions of each surgical resident, which is an important reference for further applications for Fellowship, and all Cases require superior physician certification, which is more objective and fair. Residents in Beijing only have a paper book to fill in similar information, but due to the lack of follow-up training programs, no one has referred to it, and it has not played its due role, and it is only a formality.

In terms of research, I also listed the surgical literature published by Dr. Lin Ning in recent years, so much data, professional writing, and a lot of work. Speaking of this, we can no longer use the emphasis on domestic clinical tasks as an excuse, but more because we lack similar awareness, as the saying goes or "there is no string in the head", and the environment does not have the same pressure as them.

American neurosurgery doctors are not necessarily very high IQ, but when they see them getting up at 3:30 a.m. every day to work, they think about why the same conditions, why they can have such mobility, think about how they have complained about bad conditions here, bad conditions there, hard work as a doctor in China, and so on, and suddenly blush.

Reading these literatures, I can also see that the scientific research done by the typical neurosurgeon in the United States is not the same thing as the "translational medicine" advocated by the scientific community. Dr. Lin's research is more derived from clinical problems, such as the phenomenon of lateral branch blood vessel formation around ventricular-abdominal drainage (V-P Shunt) in Patients with Moyamoya disease, the effect of morphological data on the probability of rupture of aneurysm in the middle cerebral aneurysm, statistical analysis of the clinical characteristics and prognosis of patients with negative subarachnoid hemorrhage, the relationship between the level of medical insurance and the patient's recovery after extrasophical surgery, and the effectiveness of V-P shunt and intrathecal chemotherapy in patients with neoplastic meningitis. Analyze and count the changes in the treatment method of ruptured or unruptured aneurysms in the United States, report the performance and progress of a pediatric patient's intervertebral disc cyst, analyze the difference in the growth characteristics of functional pituitary adenoma and non-functional pituitary adenoma above the first sella, report the new mechanism of thrombotic extravasation as a microvessel recandition, non-invasive monitoring of nerve function with biooptics, etc. (see attached data for details).

For American surgeons, they also have the pressure to do scientific research and publishing, but how to choose to participate in the research and progress of clinical medicine, or the work of basic research, doctors can decide according to their own situation.

In the hospital, the vast majority of surgeons, especially young surgeons, take the progress of clinical or surgical progress as the direction of their own research, on the one hand, because they graduated from medical school, professional direction and interest are here, and face a lot of clinical problems worth studying every day; on the other hand, they specialize in the progress of surgery and anatomy, parallel and corresponding statistical analysis, which is directly helpful to their clinical experience accumulation; and it is more in line with the characteristics of clinicians working long hours and less spare time.

This is very different from the current situation in China, in the field of basic research in China, there have been a large number of high-level scholars trained abroad to work back to China, but due to the lack of system integration, clinicians rarely have the opportunity to participate in clinical work and research abroad, resulting in an imbalance in the development of the two fields. The "medical research" in everyone's mind is much smaller than the scope of foreign countries, the idea is relatively narrow, mainly referring to "biotechnology research", but these studies are not the specialty of clinicians, and they are far from clinical reality, so the current domestic SCI assessment pressure makes many surgeons in grass-roots hospitals get by clinically, and as long as surgery and patients are "roughly passable", they have to hurry to worry about the problem of basic research, which does not reflect the original intention of "scientific research to promote clinical".

How to reasonably guide the motivation and energy of Chinese doctors to participate in research, in the field where they are better at and need them more, is the next problem we need to think about, and those who rarely pay attention to "medical science research" and broader "epidemiological research" may be a breakthrough and growth point in the future development of Chinese medical science.