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Results 1 - 12 of 12
1. Independence, supervision, and patient safety in residency training

By Kenneth M. Ludmerer


Since the late nineteenth century, medical educators have believed that there is one best way to produce outstanding physicians: put interns, residents, and specialty fellows to work in learning their fields. After appropriate scientific preparation during medical school, house officers (the generic term for interns, residents, and specialty fellows) need to jump into the clinical setting and begin caring for patients themselves. This means delegating to house officers the authority to write orders, make important management decisions, and perform major procedures. It is axiomatic in medicine that an individual is not a mature physician until he has learned to care for patients independently. Thus, the assumption of responsibility is the defining principle of graduate medical education.

To develop independence, house officers receive major responsibilities for the care of their patients. They typically are the first to evaluate the patient on admission, speak with the patients on rounds, make all the decisions, write the orders and progress notes, perform the procedures, and are the first to be called should a problem arise with one of their patients. Such responsibility allows house officers not only to develop independence but also to acquire ownership of their patients — the sense that the patients are theirs, that they are the ones responsible for their patients’ medical outcomes and well-being. Medical educators view the assumption of responsibility as the factor that transforms physicians-in-training into capable practitioners.

By National Cancer Institute [Public domain], via Wikimedia Commons

By National Cancer Institute Public domain via Wikimedia Commons.

Independence and responsibility are not given to house officers cavalierly. Rather, they are earned by residents who show themselves to be mature and capable. Responsibility is typically provided in “graded” fashion — that is, junior house officers have much more circumscribed responsibilities, while more experienced house officers who have accomplished their earlier tasks well are advanced to positions of greater responsibility. The more a resident has progressed, the more independence that resident receives.

The assumption of independence and responsibility comes at different rates for different house officers. Advancement to positions of greater responsibility occurs relatively quickly in cognitive fields like neurology, pediatrics, and internal medicine. There, assistant residents in their second or third year receive decision-making authority even for very sick individuals. Among these fields, house officers in pediatrics are generally monitored more closely because of the fragility of their patients, particularly babies and toddlers. Advancement occurs more slowly in procedural fields, such as general surgery, obstetrics and gynecology, and the surgical subspecialties. In these fields, technical proficiency is so important that residents have to wait many years, sometimes until they are chief residents, to perform certain major operations. The degree of independence afforded house officers also depends on the traditions and culture of individual hospitals. At community hospitals, where private physicians are in charge of their own private patients, house officers often receive too little responsibility. At municipal and county hospitals, where charity patients predominate and teaching staffs are often small, house officers can easily receive too much.

The assumption of responsibility does not mean there is no supervision of house officers. Quite the contrary. House officers are accountable to the chief of service, they have regular contact with attending physicians, and chief residents keep an extremely close eye on the resident service. Moreover, someone more senior is typically present or, if not physically present, immediately available. Thus, interns are closely watched by junior residents, junior residents by senior residents, and senior residents by the chief resident. One generation teaches and supervises the next, even though these generations are separated only by a year or two. Backup and support are available for all residents from attending physicians, consultants, and the chiefs of service. The gravest moral offense a house officer can commit is not to call for help.

From the perspective of patient safety, it may seem that patients should be seen only by experienced physicians and surgeons. However, medical educators have recognized all along that this is not a viable option. Medical education incurs the dual responsibility for ensuring the current safety of patients seen during the training process and the future safety of patients of tomorrow seen by those undergoing training today. Every physician needs to gain clinical experience, and every physician faces a day of reckoning when he practices medicine independently for the first time—that is, without anyone looking over his shoulder or immediately available for help. The only choice medical educators have is to control the circumstances in which this will happen. Should house officers gain experience and develop independence within the structured confines of a teaching hospital, where help can readily be obtained, or must this occur afterward in practice at the potential expense of the first patients who present themselves?

Thus, maximizing safety in graduate medical education is a complex task, for the needs of both present and future patients must be taken into account. The system of graded responsibility provided house officers by the residency system, coupled with careful supervision of house officers’ work, has been developed to maximize professional growth among trainees while at the same time maximizing the safety of patients entrusted to them for care. The system is not perfect, but no one in the United States or anywhere else has yet come up with a better system, and it continues to serve the public well.

Kenneth M. Ludmerer is Professor of Medicine and the Mabel Dorn Reeder Distinguished Professor of the History of Medicine at the Washington University School of Medicine. He is the author of the forthcoming Let Me Heal: The Opportunity to Preserve Excellence in American Medicine (1 October 2014), Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (1999), and Learning to Heal: The Development of American Medical Education (Basic Books, 1985).

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The post Independence, supervision, and patient safety in residency training appeared first on OUPblog.

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2. The July effect

By Kenneth M. Ludmerer


“Don’t get sick in July.”

medical studentsSo the old adage goes. For generations medical educators have uttered this exhortation, based on a perceived increase in the incidence of medical and surgical errors and complications occurring at this time of year, owing to the influx of new medical graduates (interns) into residency programs at teaching hospitals. This phenomenon is known as the “July effect.”

The existence of a July effect is highly plausible. In late June and early July of each year, all interns and residents (physicians in training beyond the internship) are at their most inexperienced. Interns—newly minted MDs fresh out of medical school—have nascent clinical skills. Most interns also have to learn how a new hospital system operates since most of them enter residency programs at hospitals other than the ones they trained at as medical students. At the same time the previous year’s interns and residents take a step up on the training ladder, assuming new duties and responsibilities. Every trainee is in a position of new and increased responsibilities. The widespread concern that these circumstances lead to mistakes is understandable.

Yet, despite considerable consternation, evidence that there is a July effect is surprisingly hard to come by. Numerous studies of medical and surgical trainees have demonstrated no increase in errors or complications in July compared with other times of the year. Many commentators have declared the July effect a myth, or at least highly exaggerated. A few studies have shown the existence of a July effect, but only a slight one—for instance, on the sickest group of heart patients, where even a slight, seemingly inconsequential mistake can have grave consequences. Even here, however, the magnitude of the effect does not appear large, and the studies are highly flawed. Certainly, there is no reason for individuals to avoid seeking medical care in July should they become ill.

That the July effect is so difficult to demonstrate is a tribute to our country’s system of graduate medical education. Every house officer (the generic term for intern and resident) is supervised in his or her work by someone more experienced, even if only a year or two farther along. Faculty members commonly provide more intense supervision in July than at other times of the year. Recent changes in residency training, such as shortening the work hours of house officers and providing them more help with chores, may also help make residency training safer for patients—in July, and throughout the year.

Uncertainty is intrinsic to medical practice. Medical and surgical care, no matter how skillfully executed, inevitably involves risks. It would not be surprising if a small July effect at teaching hospitals does occur, particularly in certain subgroups of critically ill or vulnerable patients, given that house officers are the least experienced. However, the fact that this effect, if present, is small and difficult to measure provides testimony to the strength of graduate medical education in the United States. Indeed, the quality of care at teaching hospitals has consistently been shown to be better than at hospitals without interns and residents. Patients may be assured that their interests will be served at teaching hospitals—in July, and throughout the year.

Kenneth M. Ludmerer is Professor of Medicine and the Mabel Dorn Reeder Distinguished Professor of the History of Medicine at the Washington University School of Medicine. He is the author of Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, and Learning to Heal: The Development of American Medical Education.

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Image credit: Multiracial medical students wearing lab coats studying in classroom. Photo by goldenKB, iStockphoto.

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3. Our terrific interns

origami2 300x348 Our terrific internsYesterday I was tidying up my new office and found these little origami items left by my marvelous spring semester design intern, August Lah. Most of the time I keep her pretty busy, but on days when there’s a lot of scanning, it’s hurry-up-and-wait time. Place the book on the scanner, click on Preview, crop, then wait 20-30 seconds while the scanner captures the image. Multiply by 90 images in the book review section. Ugh.

What to do during that brief down-time? August says she is a fiddler by nature, so anytime she can get her hands on a scrap of paper (post-it note, gum wrapper) she folds it into something better. August is waaay beyond me in origami intelligence. She says she’s only memorized a few shapes, but she’s good enough to be able to improvise new forms, too.

This little find just reinforced for me how much we all depend on our interns. Not only do they help us with on some of the more mundane tasks in our jobs, but most times I also learn from them — a new Photoshop shortcut, a cool website with free grunge fonts…or a new origami animal. Most of us here were once interns ourselves, some for this very company, and it’s still the best way to get started in the field.

The deadline for summer intern positions is April 15, which is next Tuesday. There are two or three editorial slots available and one design slot. Check out the application information here.

origami1 300x430 Our terrific interns

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4. The End of Unpaid Internships

Internships are addressed with increasing frequency on Cartoon Brew. While there is value to the concept of internships, too many studios use internships as a means to free labor for their animated projects. The practice is both unethical and illegal.

Time published a piece earlier this month suggesting that the era of unpaid internships may be coming to an end. It’s a good introduction to the issues surrounding interning and a must-read for any student.

The growing backlash to unpaid internships is not limited to just the animation industry. Companies who are accused of wrongdoing in the Time article include movie studios (Fox Searchlight), TV shows (PBS’s The Charlie Rose Show), and magazines (Harper’s Bazaar). More and more workers who have been victimized are filing lawsuits against their employers, a trend that could eventually pressure the US government to more strictly enforce labor laws regarding interns.

If you work in the animation industry and feel you have been subjected to an unfair labor situation, please contact me (names and contact info will be kept confidential). I can’t follow up on every request, but Cartoon Brew will continue to bring light to labor issues as much as possible.

(Photo of girl via Shutterstock)


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5. Good News, Bad News for Interns

The Wall Street Journal reported yesterday that, according to a study by the nonprofit National Association of Colleges and Employers, employers plan to hire 8.5% more interns this year. This data is based on a poll of 280 companies, “most of them large firms that recruit on campuses, between November and January.” While American companies plan to hire more than 40,000 interns this year, the projected average intern wage will fall to $16.20, from $16.70 last year.

If you’re working in animation and have interned at a company recently, share your experiences in the comments. Is your studio paying you at least $16 an hour to intern? We already know that many unpaid internships in animation are illegal, and that some studios pay professional full-time employees less than average intern wages. Knowledge is power, especially in the animation industry.


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6. Interns, On having

Once upon a time, I wrote a list of things that were important for shadows to know. I thought that I had really nailed it then, but in hind sight - I've learned that there is something even better than a shadow. Interns.I like having interns.These eager folks volunteer (at least here) for up to 40 hours a week. I sort of can't imagine what life was like without them. I used to think having an

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7. Linked Up: Intern edition!!!

You know what the best thing about having interns is? You can get them to do your work for you have the privilege of teaching them what you know, and watching them grow professionally. This week, we bring you a special Linked Up, written by publicity interns extraordinaire, Alexandra McGinn and Hanna Oldsman. Be sure to check back next week for my (awesome/hilarious) Q & A with them.

I think I may want to move to Japan and make pizza. [Reuters]

The Good News: Thanksgiving isn’t a reason to break up. The Bad News: Christmas comes shortly after Thanksgiving. [Popfi]

I’m more of a Garamond type of girl myself. [Not Cot]

If you’re still in a candy coma from Halloween it’s time to let the goods go.

The Shining’s not so scary in Lego form. [Flickr]

Obama the Grinch Steals Christmas In Tea Party Picture Book [Gawker]

Commute via holograph? Yes please! [Wired]

C the difference? [Virtual Linguist]

Van Gogh would have bought an iPad. [BBC]

Which literary character is a Facebook addict? [Salon]

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8. Welcome to DGLM, Stephanie DeVita!

by Stephanie

Hi blog readers! Now that both Jane and Chasya have so kindly introduced me, it’s my turn to chime in. I guess the best way to begin is to give you a little information on my background here. I may be new to the website, but I’m not entirely new to the blog. In fact, I have actually been puttering around this office for longer than you think.

I began at Dystel & Goderich over a year ago as an intern. I was determined to find myself an internship in publishing, particularly during the latter half of my college career. I hadn’t had much luck early on, so by my third year at NYU, nothing was going to stop me. I applied and interviewed for the internship with DGLM all while living in London, where I was spending the spring semester of my junior year. Fully aware that my geographical gap could create a handicap, I knew I had to be persistent. And luckily for me, according to Lauren, I was persistent enough that it exhibited my determination, but not too persistent that it made her want to burn my application and any remaining evidence of my existence. So with that, I was offered the chance to join DGLM that summer as an intern. The semesters passed, I continued to stay with the agency, and before I knew it about a year and a half had gone by and I had graduated from NYU. Then I was lucky enough to be given the opportunity by Jane and Miriam to take over for Chasya as she looks to begin a new chapter in her life. I knew that the timing was right; I felt comfortable here, and I had spent enough time working on the less essential tasks that I had developed the desire to explore the business further and carve out my own place in it. And as clichés go, the rest is history.

In giving this blog post some thought, I remembered something Rachel had said in her welcome post: “I think the one thing I truly love about working in a literary agency is that I get to see the entire process of publishing, from a rough manuscript to a finished book on the shelves.” I might make fun of Rachel for her love of Vegemite, but her words are very true. I’m very excited to finally get the chance to dive in and take on my own work. My time at DGLM has allowed me to expose myself to an industry I have always wanted to be a part of, and now it’s allowing me to embark on a new journey in my life—one that will allow me to build the career I’ve always wanted.

The bottom line is, I’m excited to take on this new responsibility within Dystel & Goderich, because now I get to hear from you. Yes, you. I look forward to hearing your ideas, your thoughts, your opinions. You all have stories to tell. Trust me, I’ve read a lot of them. But now I’m ready to do something with them. Turn them into the books they deserve to be. There are certain subjects I’m particularly interested in reading, which you can find in my bio on our website. So let me hear from you. I can only rearrange the pens on my desk for so long….

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9. Eve, All Hallows

One of the hot parts of being a special librarian, who runs his own library...is that you get interns from foriegn countries! OMG! I bet you didn't know that. There are tons of perks. Including ordering things from Gaylord, wearing a lab jacket, accidentally falling asleep at your desk, putting people on hold so you sound busier than you are, and no filter on your internet searches! Meet my

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10. Why I Am An Agent (Chasya)

by Chasya

Sick and confined to bed this weekend, I gazed aimlessly at the television during the few short hours I managed to stay awake hoping for some distraction from the painful knot in my throat. At some point I switched away from TLC’s Cake Boss marathon for a second, only to catch Jeremy Piven’s Ari Gold screeching at someone or another (Kevin Connolly, maybe? I’m not really sure, in my Theraflu-induced haze I wasn’t processing much). Which gets me thinking, now that I’m less fuzzy-brained, about agents and why, despite the stress of it all--particularly during a difficult and uncertain time for this business--I became one myself.

First things first, let me dispel the myth that agents are screeching Ari Gold-like banshees. Obviously he’s a caricature of an agent (even if he is based on a real person). But aside from that, we in publishing like to think that the industry is a bit more genteel than Hollywood.

So if I don’t get to yell at people on the phone all day long, you ask, why did I become an agent? Well, it just started with an old-fashioned case of wide-eyed idealism and took off from there. As with many of the people you’ll find populating publishing, some of the most memorable moments of my life involved books. Those moments led me to define myself as an ardent book-lover. For instance, when I was five my neighbors would come over to my house, and I would feel very important as I read to them all aloud. We went through the entire Disney series that my mother had been purchasing one by one at the grocery store. When I was in the fourth grade and trying to plow through as many books as I could in Mrs. Rosen’s library, I was reading one afternoon on the bus ride home and was so absorbed that I kept on reading despite intense motion sickness and had to get off at another kid’s stop just to puke. I got back on after the driver nearly pulled away and resumed reading. When I first read Jonathan Swift’s A Modest Proposal in junior high it almost made my head spin and fall off. I was enamored. I wanted to marry Jonathan Swift. Who would think an essay about eating babies could do that to a person? There are a multitude of these small, seemingly unimportant moments, but I won’t embarrass myself further by trying to relay them in any earnest sort of way. All I can say is that now, for many, many tiny reasons, I really love books.

And that love affair blossomed into a so-called useless degree in English literature. One that many students pursue, wondering “What am I supposed to do with this?”

I knew I wanted to do something practical. I knew I wanted to work in publishing and be a cog in the great machine that produced those things I was so impressed by. So I did what you do when you start out in publishing--I got an internship.

The business turned out to be far more complex and fascinating than I could have ever imagined and led me to want to stick around. Especially now, as it undergoes significant changes, it will be interesting to see how things progress. The things I wouldn’t really say aloud anymore (but appear to have less of a problem putting in print) are still there. But now what drives me is the added bonus of helping clients pursue their goals and guide them through the process. It’s rewarding and fun, even if it’s challenging.

But I can’t be the only one with these types of memories--and I certainly shouldn’t be the only one to admit them! What small moments led to your love of books?

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11. The decade of...

by Jessica

Intern Kara just told me that a blog in the Baltimore Sun declared that this was the "Twilight Decade."

Clearly, Stephanie Meyer has made a mark—and whether she is symptom or cause, we are deep inside a paranormal moment in pop-culture. Austen and the undead, who would have thought? Still, as Kara (who argued that the past ten years belong to Harry Potter) demonstrated, the “Twilight decade” is subject to some debate. I’m curious to see where you all weigh in. In the name of what author, idea or impulse, do you name the past nine years? And, incidentally, what do we name this decade? The “aughts” just never caught on.

My own answer—in terms of book-publishing, public policy, and in personal life— might be that these last ten years have been the decade of the Middle East.

Starting with 9/11 and the attendant wars begun in Afghanistan (not actually the Middle East, I know), in Iraq and on terror, to concern with radical Islam, to the scramble to understand “why they hate us,” through to present anxieties over a nuclear Iran, it was a discussion that was conducted across the media, one that taught us a new vocabulary of terrible and heartbreaking phrases: Al Qaeda, Clash of Civilization, extraordinary rendition, Abu Ghraib, improvised explosive devices…and the list goes on. The books that have emerged from and informed this discussion are too numerous to list, but they include the works of Bernard Lewis, Stephen Coll, Lawrence Wright, Dexter Filkins, Jane Mayer, Stephen Kinzer, Reza Aslan, Karen Armstrong, Juan Cole, John Esposito, etc. “Middle East Studies” is category that has grown by leaps and bounds and for better and for worse.

My decade of the Middle East is, of course, a smaller story and a happier one, a brighter and more hopeful counterpoint to the grim meta-narrative of tragedy and turmoil. Granted mine was made up of words like motherhood (my son was born in Cairo), Mahfouz (plus a host of other remarkable novelists whose work I came to know), meshi (vegetables stuffed with rice and meat, and assorted other delicious staples of Egyptian cooking), and so on…. But the opportunity to live and travel in the Islamic world, to see that devout is not, in fact, a synonym for dangerous, was eye-opening. And even though I’m back in the USA as the decade closes, my sojourn in Egypt profoundly colored this period of my life.

So obviously, this is a subjective exercise, one with no single answer: I look forward to reading your nominations.

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12. Why I Am an Agent (Michael)

by Michael

I figure it’s my turn to explain why it is I do what I do, as Jane, Jim, Lauren, Chasya, and Rachel have—if only to satisfy the clients who keep asking when I’d do one of these!

It all started at the end of the last decade, December of 1999. It was my senior year, and I really needed a job. I had no idea what to do, and was thinking of finding something in retail, as I love a good discount. But my friend Jim McCarthy told me that the literary agency where he was interning was looking for another paid intern. Now, Jim had told me what he was doing, but frankly I never quite understood. These people were agents for authors? Why did authors need agents? And isn’t publishing for rich kids who want a hobby career? Though I didn’t think it was the job or industry for me, I figured it couldn’t hurt to go in and interview.

Like Jim, I was interviewed by Stacey Glick. If you talk to her, she’ll tell you that I had blue hair at the time. This is not true. I had bright, bleached-blond hair. The blue hair came later. (And the blue dye largely ran out of my hair when I had to make a delivery to one of our most important clients in the pouring rain that summer.) I believe she hired me on the spot, and I started working Friday of the same week.
I had no idea what I was doing in the beginning. I did what people requested, paid lots of attention, and started asking questions. Slowly, but surely, I came to be very interested and involved in what was going on at the agency. I’d loved books growing up, but I’d not been the same kind of reader in college. It was great to get back to reading things that were fresh, new and contemporary. And, as I looked around, I liked what I saw: a group of smart, creative, engaged, interesting people helping authors manage their careers. Just a few short months later, I was hooked—on publishing, agenting, and DGLM. When Jane and Miriam offered me a job in September of that year, I was honored, and I jumped at the chance.

When I started full-time, I was doing much of what I did as an intern, along with managing royalties and helping Jane with submissions. But quickly, I took on new responsibilities. I began assisting the rights director, learning the ins and outs of the foreign and domestic rights markets. When she left the agency a few years later, I took over the agency’s rights, eventually attending the London Book Fair with Jane and selling rights around the world. At the same time, I was building a list of my own, something Jane encouraged me to do within my first year at the agency. I started representing children’s books at Jane’s suggestion, something I was unsure of at the time(!). But quickly I found that I had a passion for middle grade and YA books, and my career as an agent really took off then. Several years ago now, I became a full agent, and the talented Lauren Abramo took over as our rights director, freeing me up to focus on my own projects.
Last year I was very excited to be promoted to vice president at the agency, and just as pleased this past December when I moved to Los Angeles to open a West Coast office for DGLM. I tell people all the time—I’d never have had these opportunities at any other agency or in any other job, and I’m forever grateful to Jane for that.

Our industry is going through big, drastic, challenging changes, and I’m glad that Jane, Miriam, the rest of the DGLM staff and I are working together to attack them head-on. My ten-year journey with the agency has been full of amazing experiences and opportunities, and I am just as enthusiastic about the ten

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