Why Is There So Much Scut Work Our Intern Year?

Every year, usually in May, nearly 20,000 students graduate from American medical schools.

It is an exciting time. Graduating from an American medical school is a profound achievement. Over the course of four years, students are inundated with new information. They are constantly assessed with written and objective structured clinical examinations. They learn how to navigate a new and unforgiving hospital ecosystem. They are repeatedly subjected to stressful, career-defining board examinations that often test concepts with limited clinical relevance.

But as I watch this newest crop of medical students graduate, I cannot help but feel disheartened. In the next month, nearly all of America’s newest doctors will enter the American medical system as interns. Over the coming year, they will sacrifice their educations, their time, their mental and physical health, and their youth in service of a system that was not designed to meet their needs. The price of donning their new long white coats will be high.

These new interns will spend far too much time navigating electronic medical records (EMRs), which will hamper their development as competent physicians. As a result, they will have fewer opportunities for didactics and chances to interact with patients face-to-face, both of which are crucial to developing their clinical skills. A recent JAMA study that tracked the activities of 80 interns, in fact, found that they spent nearly half of their time interacting with an EMR. Only 20 percent of their time was spent on either direct patient care (13 percent) or educational activities (7 percent).

They also will spend an inexcusable amount of time performing non-medical tasks or scut work. These tasks are largely viewed as “non-educational” and generally do not contribute to the growth of physicians. Instead, they contribute to burnout and take away from educational activities and direct patient care. Despite growing calls for change, scut work still threatens to harm interns and hinders their development. It is nowhere close to being eradicated.

Combined with all of the stressors that come with being a new doctor, these factors will threaten interns’ mental health. Burnout and depression are already widespread among American physicians. But interns will face a multitude of new and unique challenges to their well-being next year, including a chronic lack of sleep, emotionally challenging patient interactions, excessive scut work, and non-dynamic EMRs. They will thus be at high risk for both burnout and depression.

All of this may jeopardize their physical health, too. Telomeres are located at the ends of chromosomes and shorten with each cell division. With increasing age, telomeres are known to shorten. A recent study published in Biological Psychiatry found that this process may occur at a significantly accelerated rate in interns. The study examined the telomeres of 250 interns during the 2015-2016 academic year and found that they shortened at a rate that was six times faster than would be expected under normal conditions. Interns who worked longer hours suffered the greatest decreases in telomere length. The study’s authors implicated the effects of chronic stress as a likely factor in these results.

All of this points to a fundamental need to change the structure of intern year, if not the medical system as a whole. As it stands, the American medical system views the primary responsibilities of interns as navigating EMRs (by entering orders and writing notes) and performing scut work. Such an approach is wasteful, underutilizing the extraordinary talents that interns possess, and does them a profound disservice. Little personal growth comes from learning how to mindlessly navigate an EMR or send a fax.

Instead, interns should be allowed to master their craft. This would require that they spend far more time with patients and in didactics, and far less time sitting in front of a computer and doing scut work than they currently do. And interns should be given more regular time off for healing and rejuvenation. To fill in the gaps, residents and attendings could help out by divvying up any additional tasks that must be completed. Increasing the use of medical scribes could help alleviate the burden of documentation.

Sadly, none of these changes are likely to be adopted anytime soon. Our medical system has historically been highly resistant to change. Furthermore, there is little incentive for residents and attendings who have gone through the system to all of a sudden embrace a new model that would require them to take on new, admittedly burdensome assignments. But the status quo is incredibly inefficient, deemphasizes the importance of medical education and direct patient care, and damages the mental and physical health of interns. It is time for a change.

The price of the long white coat should not be so unacceptably high

Kunal Sindhu, MD is a resident physician in New York City and a 2018–2019 Doximity Author. You can follow him on Twitter @sindhu_kunal.


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