I know that this discussion can get very heated but speaking from a patient perspective I want a well-rested doctor, one who is less likely to make mistakes. With physician error as one of the leading causes of death in the US has anyone ever done any studies that link this to overtiredness? I'm just interested. Why is the culture of medicine so ingrained that it is OK for people to work insane hours.

A month ago while volunteering at the hospital I watched this 9 month pregnant resident stumble her way through a 24 hour shift. I asked her when she was due and she said "this Friday", merely 3 days away. How is this OK? Surely this in turn has consequences for her health and the health of her baby.

Anyhow, I could go on, but enlighten me to the realities of the situation.
More info on the work hour issue...
http://www.amsa.org/hp/resworkfaq.cfm

Sethina, it is a problem...but is getting better as the public becomes more aware, and as residents say "enough!"

I think 'way back when', doctors used to get paid lots of money, and was very much male dominated. As times change, docs make far less money, and more women are choosing medicine. What this means is, residents are unwilling to sacrifice themselves, and delay gratification, as the "light at the end of the tunnel" dims. Also, women are more vocal about being abused, and refuse to tolerate 36 hour shifts. This is a good thing.

Yes, there were days, post call, when I was dozing off driving...or had to endure clinic from 1-5pm after spending the night up on the medicine wards. It's torture!! Not to mention your mental and physical health deteriorating because of lack of sleep/rest, food, and stress release.

There was an article in the LA Times a year ago where one resident actually said "there are times I wish a patient would just die already, so I can get back to sleep." Now tell me, no one would want that doctor overseeing their care. And let me tell you, that resident is not alone in his thinking. Just sit in the residents lounge at any overly busy hospital where the residents do every job except that of a doctor, and listen to what they're saying. It's time for a change.

Some argue that the education of the residents is compromised if they are allowed to work less than 120 hours/week. C'mon, how much do you think they are learning after being up 36 consectutive hours? I'd argre that they'd learn more in 12 hours on, 12 hours off, then 12 hours on again (36 hours) than 36 hours without rest.

I think that medicine has been an "old boys club" and residency is the hazing process. Working insane hours is not about *education* or what's good for the young doctor (or the patients)...it's about "I did it so you do it" and it's about "cheap labor." These old bats who are against it are the same old farts that fear change. It was wrong then, and it's wrong now.

Can you believe that the ACS (American College of Surgeons) actually feels as if surgery residents should be exempt from the work-hour rules because they are *surgery*. As if surgery residents are superhuman and don't require sleep or food. But you know what...that's what they think.

Why did a young doctor have to die...and many patients have to die, before someone finally said, "hey, you know what? maybe working people 120 hours a week isn't a good thing." How many residents out there have ever been in a post-call accident (or near accident) or know someone who has? How many residents out there can think of a mistake made post-call, that would have been avoided if you could only *think*?

They say that people who've been sleep deprived for more than 36 hours function as if they have a blood alcohol level of 0.1 - which is legally drunk in all 50 states. Pilots, truck-drivers, and many other professions (in which alertness is a necessity) have limitations on work hours, but somehow medicine has managed to exempt themselves. Now that people are more aware, and the young docs are more vocal...putting in legislation an all...the (old) medical community is forced to "deal with" the issue.

Women are the best thing that happened to medicine!!

A lot of excellent points, Mya. I agree that as more women enter into medicine, there will be more changes, but not without losing the respect of some of our elder physicians. I have seen it in residency and also in private practice. That is the price we will need to pay for our speaking up.

Another issue that I do not think is considered is that there is so much more to DO in medicine. My mother is an RN and recalls the days in the late 50's, early 60's, before the days of the "code blue"; if a pt was having an MI or other cardiac compromise, there was little to do but maybe put on some supplemental oxygen...there were no emergent cardiac caths, no middle of the night transplants or organ donors, no emergent cardioversions for dangerous dysrhythmias, no multitude of drugs to choose from and titrate to hemodynamic effect; heck, there was not even CPR! If a patient was dying, he was dying and all you could do was offer some morphine for the pain. Now there is so much more to be done....all great for the patients (and us as future patients), but extremely taxing on the resident as they race from one bedside to another to provide the standard of technological care.

I recall as an intern doing a yr of internal medicine before beginning my anesthesiology residency, being on call with my resident in the MICU/CICU at a large teaching hospital. We had 14 critical care emergencies and I was cross covering for over 30 other ICU patients. We had four deaths, four! The resident called the cardiology fellow twice, begging for help with a dying MI pt, among all the other crises, but he refused to come in. The next day, we were severly chastised by the attending for not calling for help, yet the resident did not say that she did in from of the whole group, for fear of suffering the consequences of serving up the fellow's lack of help to the angry attending. It was the most awful 36 hours of my life and there is nobody who could have dealt with that situation adequately.

I have also stumbled through long days/nights while pregnant (worked until the day I went into labor), but that was private practice, and I felt I had no choice but to keep up my fair share with my partners, who felt that was my duty. About the only thing they did for me was to swap cases in the OR that would include radiation.

But beware the disdain of those gentlmen who practiced in the "golden age of medicine" as it has been described to me by a physician in practice since 1958. They will not respect physicians who will not give up their entire life for medicine, who "whine" about hard work (that is the word they would use, not me). But I think if they were honest with themselves, they would have to acknowledge that the rewards in medicine are just not there anymore...they know it better than we younger docs who only hear about malpractice nightmares, 3rd party payers who scheme to devise more ways to deny payment to us, and patients who seem to have developed expectations about what we can do for them faster than what medical science can keep up with. I am not sure what is to be done.

I am young and people who whine (audibly) about hours still bug me- so even when residency is over and you are working in the real world there are some LONG hours that need to be done...and I don't recall anyone feeling sorry for me or letting me leave clinic early...It would be great if residency was easier but it may not reflect your life later...
and a lot of those elderly physicians who took care of towns for 40 years were not millionairres by any stretch, but they did enjoy less legal issues/ Medicare violations.

having delirious, exhausted physicians with little experience walking around in a daze from lack of sleep and overwork (because that's what must be done, or that's what the old boys did) IS PURE LUNACY. Even as far as irresponsible, idiotic and dangerous. The day people realize that this should be the first thing to be changed in the culture of medicine EVERYONE (physicians and patients alike) will be better off. I'm all for whining - stand up and complain. but I do totally understand the fear of personal repercussions, a united body speaking might have more impact (as the AMSA are attempting to do). United we stand! If truck drivers can only drive certain hours per day to prevent danger due to overtiredness, why the h*** not for doctors who are in charge of PEOPLE'S LIVES? Only men would come up with such a system

I would add that even 20-30 years ago residency and the practice of medicine was much different than it is today. A resident may have taken regular q3 call but patients were likely back then to stay in the hospital longer (so the residents knew them and their health problems) and did not come in quite as sick. Today in our quick-fix healthcare system residents deal with multiple admissions and discharges all day and night long. They are constantly rounding on new patients....it wasn't always like that. Many of the old docs that I have talked to confess that the residents today generally have to work much harder when they are 'on' than they had to. They also admit to having less medical school debt in relation to their incomes as well.

Things are different today. Change is necessary.

Speaking out...whining...whatever!!

When you get out, sure there are long hours of work...but then there's that 150,000-200,000 dollar motivator and job security. Oh, and the fact that as a physician specialist you do way less scut than the average intern/resident. To say that, I work hard even after I'm out, so you all suck it up and quit whining...is inappropriate. We all expect to work hard, just not for 36 hours straight. And if "speaking out" is your interpretation of whining...then WAAAHHHHH!! :weeping:

Some things are just wrong, anyway you look at it. And there is no way to justify jeapordizing patient's lives for the sake of "tradition." Period.

I have little to add to what has already been stated other than pray that I nor any loved one should have to be a patient in those conditions under which many of us have trained. When I was in training many of us thought to wear a medic alert bracelet should we be taken unconscious to a teaching hospital by ambulance. The bracelet would read "please DO NOT transport me to such and such hospitals".

All any of us have to consider in this "debate" is whether we or our loved ones would accept being one of those many, many critical patients that Taurus and her resident had to care for that one hideous night that the cardiac fellow abandoned them. I am not stating that as patients we should stay out of teaching hospitals all together but the mainstay of patient safety rests upon adequate rest, staffing and access to experienced physician input.

I think the sleep deprivation issue is HUGE, and I'm glad the regulations have changed. Yes, mistakes do happen and it's scary. I did a 117 hour week in my surgery rotation during residency. (see sleep deprivation thread). I actually head-bobbed while in the OR, it scared the piss out of me ( thankfully I didn't have my hands in the patient at the time ).
I also knew a guy who got in a car accident post-call, he fell asleep at the wheel. He ended up having to take a year off for PT because he broke his legs multiple times and still has a limp. How is that educationally beneficial?

It is 100% time for a radical change in the way we educate young doctors. I think someone hit the nail on the head...way back when everyone was walking-2-miles-a-day-to-school-against-in-the-wind-in-3-feet-of-snow-uphill-bot h-ways - in the "golden" days of medicine they actually got to sleep while on call.

On of the rotations here (CV Surg ICU) the resident used to live in the unit for several months at a time...they could have visitors, but could not leave . The staff and attendings that had lived through that was laughing about how they used to have a barber come in to cut their hair and how their wives would bring their kids to see them, etc., etc.. Now I've done my time in that unit and there aint NO time that I would have had to get my hair cut, see my kids, or even SIT DOWN for that matter. That unit is chaotic and needs your full attention 24 hours a day-without break.

So, what I took from these walks down memory lane, is not only were they not as busy, but their patients did not have the acuity that we are seeing now. To keep someone awake for ungodly periods of time, and have them taking care of the sickest patients that exist is utterly ridiculous and to any average human being makes NO SENSE AT ALL! Call it whining if you like! I didn't have an 80-hour work week for my first 2 clinical years, yet I don't think anyone else should go through that just because I did! Safe patient care should be our first goal... remember...first do no harm .

www.hourswatch.org

It's a website set up by the AMSA/Committee of Interns and Residents about resident hours reforms.

Personally, I don't want a doctor who has the equivalent of a blood alcohol level of 0.1 in charge of my life!

I am a faculty physician and have found it extremely ironic that rules are now in place for the residents' hours but not the faculty's. At our program the faculty take more frequent call than the residents and it is us whom they call at 3 AM, when they need direction and advice about the ICU pts suddenly crumping. Then, we get to work a FULL day the next day, with or without sleep on call; often giving advice as preceptors in the office where we have to stay until EVERY pt leaves the office and every resident/student has discussed EVERY case with us and we have signed EVERY chart (or at the latest, in order to be "compliant," sign them all within the next 24 hours). We aren't gonna graduate in 3 years...some of us are planning to be in those postions for decades.

Now, all of that having been said, I DO advocate placing reasonable limits on physician hours. For far too long, in our egotistical male-dominated profession, physicians have neglected their families, their own health and mental well being, and been slaves to their jobs in the name of doing something noble and service-oriented. I believe and support nobel causes and service to others (those are some of the major reasons why I am a doc in the first place), but there needs to be a reasonable balance and it's PAST time that our profession, which preaches moderation and healthy lifestyles to everyone else, begin to be role models for setting appropriate limits and balancing our lives. We are not machines; if that is what is needed, I'm sure that a computer/robot will soon be albe to replace all of us and we can finally get our rest! To be an effective healer (or honestly, an effective HUMAN BEING), we need to heal ourselves. I have found that one's practice, whether in an academic or private setting (I've done both) can become all-consuming. I am a multi-faceted individual and I refuse to swallowed whole by a career tract that I chose for myself, or be made to feel less than what I should be by some guy who looks down on my desire to go home at a reasonable hour and refuse to support the idea of a Saturday clinic, etc... Let's stand up for what is right for our patients, our families, our profession and ourselves!

Young Doctors Working Too Many Hours

A new article about compliance with the resident work hours.

Wow, that guy really had some courage! Good for him!

A subject close to my heart...

The attitude I get from attendings, as well as some of my senior residents, is that we (the newbies) have it so much easier. They imply that we are lazy slackers because we are concerned about "lifestyle", and because of the 80 hour workweek. And I am quite tired of hearing, "Well when I was an intern...". I feel like responding that just because that is they way it was, does not mean that is the way it should be. I am also tired of the implication that I am somehow deficient as a physician because I am not working the 120 hour weeks my predecessors did.

I work hard. I do the scut. I write the notes. I dictate the cases. I triage the patients. I am the one who is up writing labor or Mag notes. That's my job as the intern, whether I like it or not. And I really can't agree that taking 8 calls a month, many of them q2, is slacking.

What this residency process often feels like to me is ole fashioned hazing. The "I did this, now you have to do it," mode of thinking. As if there is nobility in the suffering. That somehow we should gladly place ourselves, our families on the alter of medicine.

I love what I do. My family and I have made many sacrifices so I could be where I am today. And I don't regret the choices I have made. But I am more than a physician. I am a mother, a wife, a sister, a woman.

I know I'm rambling on a bit... my apologies.

An aside (and a clarification)... the 80 hour week is based on an "average" over four weeks. So some weeks you can do 100 hours, and some weeks 60. The call is also not supposed to be more frequent than q3, but that too is "averaged." So it doesn't matter if I take 3 every other night calls, as long as my average is q3. Our on call days are also usually more like 30 or 31 hours, not 24. The reason is that while we should only have patient care for 24 and then do paperwork or continuity of care for a max of 6 more. That's not what happens. We work, taking care of patients for those 6 hours.

My purpose is not to whine, but to emphasize that changes are happening within medicine, and that they have to take place. My own chosen specialty, OB/Gyn, can't fill their spots with US seniors anymore. And it is not just the liability issues that have med students running from the surgical specialties. It really is a matter of "lifestyle". And threats (that exist) from these specialties to lengthen training programs will have even more people choosing other careers or specialties.

To (poorly) paraphrase the famous quote about democracy... Residency is the worst form of training doctors, but it is the best one we have so far. I'm for us finding a new and hopefully a better way of doing it.

Linda
PGY-1, OB-Gyn

Am about to go to bed, s/p 30 hour cardiology/CCU shift (would have been 36 except for new RRC rules), agree that I wouldn't want someone as delirious as myself taking care of my loved one. That being said, the solution to the work hour problem is increasing numbers of physician hand-offs. There are numerous studies in medicine relating errors to hand-offs, and none relating physician sleep-deprivation to errors (though numerous case reports). In this case, I think we can all agree despite the absence of literature that physician sleep-deprivation is dangerous. However, the patients I admitted overnight to the CCU were being managed this afternoon by someone who just briefly heard about them on rounds. We all need to be careful in the ways that we attempt to rectify the situation, that we don't actually worsen patient outcomes.