Medical school doesn’t really prepare students for anything except more school. Modern medicine has become sufficiently complex that essentially no one is able to graduate and begin to care for patients without additional training. The additional training is so important that very few states will even license a physician without it.

Residents are graduates of medical schools who are pursuing this additional training. The Accreditation Council for Graduate Medical Education (ACGME) is the body responsible for defining specialties and the required training for a physician to be called a specialist. Most residency training positions are filled in an arcane process known as “the match.” The match is run by the National Resident Matching Program (NRMP), an organization simultaneously reviled and lauded.

While still in medical school most students decide on their career in one of a large number of training programs and specialties. Subsequently the student typicall applies and interviews with the selected programs. After the residents and programs have all made their super-secret choices then the choices are fed into a giant computer. Magically, one day in March of each year the results are disclosed. On that day depression is mixed with elation as the students find where they’ll spend the next 3-7 years of their lives and more important what they’lll be doing. This is more than just residency and location selection. In a very real sense this is career selection. On the fateful day would-be orthopedic surgeons find out that they will in fact be pathologists, dermatologists find they will be internists, surgeons find they will be psychiatrists unless they are able to change programs at a later date. OK, so I’m exagerrating a bit. The match will only match what students and programs have offered as possibilities.

Resident physicians are so called because the used to “reside” in the hospital. After all medicine is a calling. The last twenty years have seen enormous changes in work conditions and hours for residents. The ACGME prohibits residents from routinely working more than 80 hours per week. Regulations further limit the number of consecutive hours a resident may work. Despite stiff penalties some prgrams continue to ignore the 80 hour work limit. Always ask the resident when he/she last slept. If the answer is more than 12 hours ago consider sending him/her away. After all if you’d been up for 20 hours and had been working for 70 hours in the last 6 days would you use a power saw or other dangerous equipment? Why would you let someone you don’t even know risk your life or health? These people are so fatigued that they can’t even drive why would they think they can make life or death decisions? Some residents are so horribly misguided, foolish, or egotistical as to believe that fatigue and sleep deprivation can “condition them.” They are wrong.

A resident’s scope of care is defined by the training program and institution. Generally each must work under the direction of a fully-trained attending physician. Under most circumstances the resdent’s entire scope of practice is further lmited by the attending physician’s supervisions and scope of practice. In essence the resident acts as an agent of the attending and all authority is delegated by the attending.

Unfortunately many attending physicians are frankly irresponsible, stupid, uncaring, or some combination of all three. In such circumstances you may find yourself having an operation at 3:00 am from a resident who has already worked 70 hours in a week and has been awake continuously since 7:00 am the prior morning. Can that happen you ask? Yes. It can. In fact depending on the hospital the resident may do so without the supervision, presence, or even the knowledge of a responsible, fully-trained surgeon. In fact some attendings are sufficiently self-serving that they will cloak their laziness in “educational concerns.” That is simply bovine excrement. Yet, it happens everyday, somewhere. Don’t let it happen to you. There is no need to be a victim of your own health care.

So why would you go to a hospital that has residents? The care is frequently better. The hospitals tend to be tertiary-care centers with large numbers of specialists who can rapidly diagnose and treat you. The residents, paradoxically, spend more time with patients than attendings (back to that caring and responsibility thing again).
The value of resident care is, however, completely dependent on hospital rules and the competence and diligence of the attending physician.

So what should you do? Ask what residents can do. Ask everyone who enters your room to identify him/herself. If a resident oprders medications, tests, or therapy ask if the attending knows and approves. Make sure that your attending physician visits everyday. If you are to have surgery ask your surgeon who will do the actual surgery. Ask what the resident’s role will be in the operating room. Do not sign the surgical consent until you see your surgeon preoperatively. Make your surgeon commit. Document your agreement in the chart and consent as to duties of the attending, resident, and medical students. Do not let them put you to sleep until/unless you see your surgeon in the operating room with you.

Similarly, if a resident is preparing to perform a minor procedure on you or a family member be equally aggressive. Assure yourself that your attending is aware or physically present, as you desire. You have the right to determine who performs what procedures.

I recall several years ago my son cut his finger while working on a ranch. The cut was not huge but needed a couple of stitches. He went to the emergency room of a university-afiliated, tertiary-care hospital. A resident closed the wound and did a nice job. A few weeks later I got a big fat bill from the hospital and a big bill from an emergency-room attending physician. Interestingly, my son had mentioned already that he only saw the resident. I called and asked for the documentation of the attending physician’s participation in the care. The hospital was unable to produce any such documentation. When I asked if they were aware that sending a bill for services not rendered was a federal offense they put me on hold. A few minutes later another person came on the line and informed me that I could ignore both of the bills and thanked me for my patience. The point is that some attendings are irresponsible, uncaring, and occassionally, frankly criminal. Residents may actually do fine work. But they are only trainees. If you let them work unsupervised you may not get the best care. In some cases you actually get inferior care that jeopardizes your health.

Residents may improve your care but it’s still best to think of them as “advanced medical students.”

It’s your health. Take care of it.