I take pride in being “old school.” Over the years, I have seen a major change in medicine in the United States. And I am not so sure I love the change.

In my medical school in the Bronx, 1994, my acquisition of procedural skill was basically: “See one, do one, teach one.” At times, it was merely: “Just do one, and then teach one.”

My earliest blood draw was on a charismatic fellow named Jesus. Jesus had a bad habit of shooting heroin, scarring up the usual veins in his arms. He really didn’t want me mucking up the one good vein he had. And so he held my trembling fingers as I stuck his vein perfectly and got the needed vial of blood. Then he did the same with the five other patients in his room at the Bronx Municipal Hospital. When I say that Jesus steadied my hand when I learned how to draw blood, I mean it.

When my surgical intern didn’t want to lose his chance to do an appendectomy, he “volun-told” me what to do get an arterial blood gas — stick a needle into a pulsating artery — on a patient in pre-op holding. He only had time to explain it to me, then said, “And don’t (expletive) it up. Otherwise, he’ll lose his hand.” Miraculously, I successfully got it done, having never seen it done before.

Those surgical residents in the Bronx would operate on gunshot wounds, stabbings and blunt trauma all night, often without an attending or even a chief resident present. Then they’d work through the next day and into the next night before taking a break. It violated the New York mandate that medical trainees not work more than 24 hours in a row, but there were just too many patients. And I know those trainees came out well trained and confident.

In my residency, while in the ICU, we stayed up on call every third night, and the next day we worked until the work was done, usually 36 hours in a row, often without sleep. Were we tired? Of course. Did we learn a ton? Absolutely. Did patient care suffer? I do not think so. Patients had better continuity of care because there was no “hand off” to someone who didn’t know all the subtleties of the case. Were things missed? Of course, but in my experience, far more things are missed by one (tired) doctor handing off care to another doctor at the end of a shift.

I recently spoke to a colleague in a different state who lamented the lack of experience and confidence of docs fresh out of residency. More docs, it seems, are opting for additional years of specialty fellowship training to improve their skill. Such fellowship-trained docs, indeed, come out of their training extremely well trained in their specialty –be it cardiology, colorectal surgery or nephrology. They are also paid far better for their training. Doctors are inadvertently being discouraged from being generalists.

Which probably explains why it is so damned hard to find a primary care physician these days.