We're not young.

Thanks for sending this version to me, Mo! Now this is something I can learn all the words to . . .while dozing off on my couch on a Saturday night. Good times, baby.

***
Happy Sabado!

A day late and a dollar short.

Trying to measure up.

"Here comes the sun
Here comes the sun
And I say. . . 
It's alright."


~ George Harrison of The Beatles
_____________________________________________

 
On December 2, 2008, The Institute of Medicine released their greatly anticipated report on “Resident Duty Hours.” Like many academic physicians, I sat in front of my computer listening to the live webcast, trying to make sense of their recommendations for more sleep and less continuous duty hours for resident physicians. I perused the New York Times article that followed, but it wasn’t until I read the subsequent barrage of online commentary that it really set in.  Let me tell you--folks were not happy.

“We are officially in the ‘No Accountability Era,’” one physician wrote. “Our patients will be the ones who suffer from the ‘clock in-clock out’ monsters that we are creating.” I read on, serving as my own amen choir with exaggerated head nods. Another passionately added, “Our residents are becoming more interested in getting out of the hospital than getting to know their patients.  No one seems to care anymore. This will only make it worse.” 

Ouch.

Next came recommendations from the Accreditation Council for Graduate Medical Education (ACGME.)  These recommendations first came as ones that weren’t etched in stone. They said, “Okay, interns—meaning first year resident physicians—need to get up out of the hospital after sixteen consecutive hours of work. Oh, and you faculty? Y’all need to do a little, no a lot, more supervising. For real.”   Okay, maybe this isn’t exactly how they said it, but that was my take on it.

After that, the ACGME solicited input from a bunch of academic institutions and professional societies.  We had a slew of institutional meetings at Emory to discuss our suggestions and with the help of leaders in our Graduate Medical Education Committee, sent them off. Organizations like the American College of Surgeons sent theirs in, too, and man. . .  they didn’t sugar coat things. Like I said. . .folks were concerned. No, more than concerned. Folks were worried. And folks meant us.

The thing is this: If an intern can’t work beyond sixteen hours straight, it means that they can’t work overnight. A lot of folks will tell you that their biggest learning during training went down in the middle of the night.  I wish I could say that I didn’t agree with that. But for me, it’s true.

Well, turns out that the ACGME came back with the official recommendations after getting all of that feedback, which essentially was:

“Okay, interns—meaning first year resident physicians—need to get up out of the hospital after sixteen consecutive hours of work. Oh, and you faculty? Y’all need to do a little, no a lot, more supervising. For real.”  

Um yeah.

Faculty weren’t so giddy about this. In fact, the “new duty hours situation” was smattered throughout our conversations in the resident continuity clinic that day. Between patients we pondered what these changes would mean to us as faculty. We worried about two years from now when more inexperienced second year residents were being expected to teach one when they hadn’t yet seen one or done one. What would that mean to us?

When the residents were out of the room, the discussion got pretty unfiltered—everyone was sharing their unsolicited stories of residency in the “real” trenches, and collectively tsk-tsk-tsking this mandate that would further pull house staff away from the hospital. Next thing we knew, the conversations kept going even with house staff around. Before we knew it, we had all exploded into a fraternity of “old school” doctors unabashedly hazing our young learners by insulting their potentially soon-to-be inferior training experience.

The irony is that there’s really nothing new under the sun. No matter when a person starts their training, there is bound to be some omission in the “new way” that appalls the village elders. We’ve all been there and felt the sting of criticism for things out of our control.  The “new way” always seems to lack the pieces necessary to build intestinal fortitude and sear the heart with nostalgia.  And it has been this way for years. The freshman experience never ceases to be a day late and a dollar short.

I can still recall this snapshot from my own internship in 1996—amid the late lunchtime crowd, I wolfed down a sandwich in the cafeteria with my senior resident following my first night on call. I couldn’t tell if the nausea that churned in my gut was a factor of the inexplicable exhaustion I felt or the pre-packaged hoagie that my two-dollar meal ticket afforded me. My upper level resident described our evening as “not so bad” when a classmate asked in passing. Not so bad? I silently protested. She must have read my mind. She turned toward me, rolled her eyes and trivialized the mere nine patients I had just admitted with the dreaded “when I was an intern” preamble.  (Major emphasis on ‘I’.)

Her, perhaps tall, tales of working up eighteen patients alone with virtually no supervision or chance of sleep in sight were further encouraged by my incredulous gasps. How could I possibly become as fearless, decisive, and knowledgeable as she with a measly one night in four call schedule and someone enforcing a patient cap? I can still feel the way my shoulders slumped down that day; ashamed for believing that it was impossible to do more than I had just done the evening before.

I grew up, and despite the patient cap and less frequent call schedule, I turned out all right. My medical knowledge increased, I accrued my own arsenal of lessons, and eventually became a clinician-educator. Time marched on, and at some point, I forgot those hunched intern shoulders. More rules came along, and eventually, I found myself duly initiated into the “old school” fraternity of those who “really” trained.

 In my ten years of teaching residents and medical students, I have certainly had moments of disappointment with their work products. But honestly, I have had far more hopeful moments about the physicians we are helping to mold. The more I reflect on the myriad of driven, selfless, and responsible residents I’ve worked with over the years, the more conflicted I feel about labeling them all products of the “No Accountability Era.” 

Our attitudes suggest that they don’t stand a chance, when the truth is that, more than likely, they really, really do. The rules were out of my control in the mid-1990’s, and today’s learners have little to no say about the current mandates. In fact, when researchers asked them what they thought about it, in a paper published last year in the New England Journal of Medicine, they made it real clear that they, too, took issue with all of these changes. Interesting situation, ain't it? 

Anyways. . . . just as we can recall the incredibly empathic and the egregiously irresponsible during our own residencies, the same exist today. Just because you work less than twenty-four hours doesn't mean you are automatically shady. Oh, and the converse absolutely applies, too--and to that I can personally attest.  Alas, there's really nothing new under the sun.

Let's be real. I can’t say that I am thrilled about the idea of trying to figure out how to do the same amount of patient service with less manpower. I also would be lying if I said I wasn’t extremely worried at times for specialties like general surgery and obstetrics and gynecology whose unpredictable schedules make the continuity of working a full twenty-four hours critical to learning the ropes. 

But still . . . I am inspired by so many of the learners I know. Many, if not most, do feel accountable for their patients. They do shed tears for their patients in a locked bathroom on the wards, and just like we did, and they are still plagued with the need to read all about their patients’ conditions.

So I guess what I’m saying is. . . .contrary to what the message boards (and sometimes we) are saying,  I can say firsthand that there are legions of caring, earnest, and accountable young physicians waiting in the wings. On July 1, these recent medical school graduates will come rushing on our hospital lawns looking for their chance to be initiated.  Now I guess it’s just up to us to find creative ways to welcome them into the fraternity.

*** 
Here comes the sun, man.  With nothing new under it. And I say? It's alright. It has to be.  
Now playing on my mental iPod (Geo. Harrison with a super-gnarly line up behind him!):

Old School meets New School.

*Warning: Completely nonmedically related and totally random post ahead.
_______________________________________________

"I hope and pray that I will, but today I am still just a bill. . ."

____________________________________

The Manning household believes in giving our kids a sho' nuff taste of the old school. Here's what we have been doing over here with our Sunday evening since finishing dinner and bathtime. . .

Whaaaaat???? What y'all know about that?

Oh yeah, baby. . . . thanks to YouTube, we've been rocking out to some classic School House Rock.


Real quick for the thirty-somethings and up--am I the only one who learned the preamble to the Constitution, the difference between a bill and a law, and all my parts of speech from these infectious little jingles? Tell me you didn't recite the preamble in a high school Civics class while pretending like you weren't singing the words to this:



You know you did. If you didn't, you are
a) not old school at all
b) somebody who grew up without a television on in your house on Saturday mornings,
c) not from this country, or
d) all of the above.

Awww. Is that you?

Okay, then let me school house rock you. This is how the Saturday ritual went down back in the day at least in my neighborhood:

• Every Saturday you woke up waaaay before your parents.
• You stumbled into the kitchen and poured yourself a giant bowl of Trix, Frankenberry, Cocoa Puffs, Sugar Corn Pops, Honeycomb, Frosted Flakes, Cap'n Crunch, or Apple Jacks.
• If your mama was on that "no sugar" kick (like ours periodically was) you instead poured a bowl of Rice Krispies or Kellogg's Corn Flakes OR-- as Harry just told me to add--that generic black and white box of just "Corn Flakes"--followed by ten heaping tablespoons of sugar that your mama had no idea you'd be slurping from the bottom of the bowl later. (Sorry, Mom.)
• You carefully carried that big-a bowl into the den, sat it on the coffee table, and then turned on the TV. (Remember when it had to warm up first?)
• Because there was only one channel with cartoons playing, even if you had several siblings, nobody ever argued over what to watch.
• Once the TV was on, you'd go back to grab the big-a bowl of now soggy cereal and sit criss cross applesauce on the floor.
• You watched cartoons from 8 AM to noon--moving only for the bathroom and to top off your cereal, after which, cartoons promptly were replaced by made for TV movies or sports.
• You did your chores.
• Your mama told you to go outside to play. For the day.
• You came back when the street lights came on.
• Oh, one caveat: If you played sports on Saturdays, you went to your game after cartoons.
• Then, when you got back, your mama told you to go outside and play. For the day.
• And you still came back when the street lights came on after riding your bike God knows where without a helmet and with a younger sibling holding onto the back of the banana seat and a next door neighbor riding on the tasseled handle bars.

Insert six year old on back (turned backwards), insert seven year old me riding, insert seven year old on handle bars.

Yeah, man. Four hours of cartoons pretty much on Saturday only and that was it. This is pre-PBSkids, pre-Disney Channel. . . .pre-cable! I'm talking bunny ears on top of the TV that sat on top of the other TV that was broken. (Y'all don't know nothin' bout the old school, man!)

But I'm sayin'. . . the Manning boys? Oh, they will know old school when the see it.

Starting with School House Rock. Here's our three favorites:







And I'm sayin' -- Zachary Manning? Oh he WILL bust out in song with any one of the above jams completely unsolicited. Especially "Interjections." Public places included. (I always feel proud when folks look at him all impressed-like at his knowledge of such old school cartoon classics.)

::smile::

Unfamiliar with the old school? That's okay. Get familiar--starting with School House Rock. And if you haven't already. . . get your kids familiar, too. (I'm just sayin'.)

The noun song. . . .


. . .but sayin' all those nouns over and over can really wear you down. . .


Zachary and I always hug each other at the end of this one. . . .



Darn! That's the end!

(Consider yourself School House Rocked.)