The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Friday, December 29, 2006

Lullabies and Lawsuits: How Sleep Deprived are Medical Residents?

Maybe the question is moot. Of course medical residents are sleep deprived. It's practically in the job description. We know it's not healthy. We know it's not a sustainable lifestyle. But it's the way it's always been done.

Stories of sleep deprivation are legendary among residents, who often share them as though they were badges of honour. One obstetrics resident spoke of falling asleep while driving home on a particularly straight stretch of highway. One of my medical school classmates confessed to driving off the road on the way home from a 36-hour shift. 'Post-call' wasn't just a description our work schedules, but a state of mind and an excuse of all sorts of mental dysfunction. It was part of the rite of passage.

In the States, this has been a much more heated topic of discussion. Since the Libby Zion case in 1984, where the death of a young woman in New York City was found to be at least in part related to extreme fatigue on the part of the residents responsible for her care. The woman's father has attacked the system responsible for the training of residents and has contended that the hospital was grossly negligent in allowing residents to practice medicine in a state of extreme fatigue. Between the Zion case and the subsequent Bell commission, the face of medical training in the US has changed dramatically in the past 20 years.

Medical residents have all worked with old-school physicians who are quick to recall the days of 'internship', where the interns were literally living in the hospital. Marriage was prohibited (at least unofficially) and the interns were paid peanuts-- occasionally out of the pockets of their supervisors. These doctors went on to become old-school doctors who never really left the hospital, and were always accessible to their patients. Admirable to some, but these are the same guys who had three wives by the age of 50 and often a brood of children to whom they were a virtual stranger. In my experience, these doctors (many of whom are now at or well past retirement age yet still hang on to hospital appointments, unable to imagine life without medicine) do not look fondly on the current crop of trainees. We're soft, our training was watered-down, and we have the audacity to feel entitled to a life outside of medicine. As I've said before, most of today's young doctors aren't willing to subject themselves to a life of 14-hour days and being on call 24 hours a day at the exclusion of family, friends and mental and physical health.

Now, residents in the US follow the 80-hour work week, as legislated by law.
The rules limit residents to an 80-hour workweek; prohibit any single stretch on duty of more than 24 hours, which must be followed by a full 24 hours off; and require at least 10 hours between shifts and at least one full day off a week. To most other professions, this is still a hellish schedule. To a Canadian resident, this is a cakewalk. In Canada, the rules are less complicated-- 'in-house' call (meaning when you work overnight in the hospital, usually with little to no sleep) is limited to one every four days. So on this 'on-call' day, you start with your team (start time could be anywhere from 6am to 8am, depending on the rotation) and you work through the day and night. On your 'post-call' day you must be excused from your duties by noon. Ideally.

These rules are haphazardly enforced. Particularly in surgical specialties, where the old-boys-club rules, leaving the hospital when you are post-call is often viewed as a sign of weakness. Many of the surgical residents don't feel that they should leave, for fear of missing an interesting case. So they work a usual 12-14 hour day after putting in a full 24-hour shift. Or, in the case of orthopedic surgery (the ultimate 'old-boys-club') they consider their call 'home call' (meaning they sleep at home and come in when needed) even though they end up spending the entire night in the OR more often than not. This allows them to be on call every three days, rather than every four days. In the province of Ontario, the Workplace and Contract Compliance Committee that is run by the resident's union is impotent in cracking down on abuses unless someone comes forward with concrete proof. And no one wants to be 'that guy'.

Ironically, the new laws aren't being implemented in the US without resistance from the very people the law is intended to protect. Residents resent being forced to restrict their work week to 80 hours, saying that their 5-year residency becomes a 3-year residency if they're forced to work 25% fewer hours. They worry that continuity of care is compromised, and that their learning is affected if they are unable to see anything through.

True, in theory. But in my experience, the stuff that residents stay post-call for has nothing to do with continuity of care. They stay to scrub in on that day's OR, or to attend clinic. Once rounds have been done and the day's plans set in motion, attention turns to the new cases. And a resident staying to scrub in isn't the one who will be called when a patient on the floor crashes anyway. That's why we have handover, so the new team will be fully informed regarding the active issues and unstable patients. Sure-- ideally, residents will always be available for 'their' patients. But that's not a realistic scenario. Maybe we should look at improving handover rather than extending resident shifts.

The other argument against the shorter work week is that patient care suffers from having less staff on. I'm not really going to argue with the fact that patients suffer when hospitals are understaffed. What I am going to disagree with is the fact that this is the responsibility of the residents to correct. Having been in the position of being responsible for two floors of very sick (and occasionally unstable) surgical patients, one half floor of pediatric surgical patients, overnight OR's and surgical consults for both adults and pediatrics through the ER during my general surgery rotation just a few months after graduating from medical school, I know all too well the feeling of panic as I put out fires and prayed that everyone would just stay alive until morning when the people who knew what they were doing would be back in the hospital. I still feel that it is totally inappropriate for such a junior resident to be faced with so much responsibility with nothing but 2-3 buddy calls with a senior resident to prepare them. If one of my parents had been a surgical patient in that hospital and had crashed with only a very junior resident to manage their care, you can bet I'd be pushing to change the system. Very loudly, and with a team of lawyers behind me. Sad that tragedy has to occur before the system is re-examined.

As for the staffing shortfall, maybe the Canadian government should look into expanding the roll of nurse practitioners, opening up more residency spots and hiring hospitalists to help shift the load from the shoulders of trainees. It can't be an impossible task-- in Europe, the average work week for residents and physicians hovers around 60 hours per week. In Scandinavia, an unheard-of 40 hours of work per week.

Just because something has 'always been done' a certain way, doesn't mean that changing it won't make it better. I don't think the American system is necessarily the solution. And I don't actually mind the way things are done here. But as recent studies have shown that sleepy residents are more likely to make medical errors than residents who aren't sleep deprived, it's clear that the system is in need of a tune-up.



Anonymous trenchdoc said...

...and residents are no where NEAR carrying the hours per week of a decade ago...

4:45 PM

Anonymous Anonymous said...

I don't usually comment on your entries, but I've been reading for a while and decided to comment on this one.

As a high school student who intends on becoming a doctor someday, the fact that I'll someday need to stay awake for so long at a time somewhat frightens me because I don't want to be responsible for any stupid mistakes just because I'm so tired I can't think clearly.

Thanks for providing an insight into the life of a medical resident - it's been really interesting, and I anxiously await your next entry.

5:21 PM

Blogger ICU 101 said...

i know i've said this to you before, but i'll say it again: my first set of shifts in a teaching hospital cured me of any fantasy that i wanted to go on to med school... the residency system sucks...

i see the residents going through our ICU get the "well, it's what we had to do, so suck it up" speech from our attendings all the time... while it may be the way it was, it doesn't mean it right... and even though there's the out by noon post-call rule, it's actually frowned upon by the attendings if the resident leaves before they've clued up their work... yet the same attendings have all the sympathy in the world for nursing staff and reassure them that "it's a 24 hour job, and you can't always get everything done on your shift"...

from a nursing perspective, an over-tired resident is often useless when it comes to performing procedures... no, i'd rather you'd get the person who's on call tonight to put in that art line instead of you poking my patient multiple times and making the site useless for anyone else...

from patient perspective, even in an ICU where turn over can be fast, people do get continuity of care... and having different people follow a patient isn't always a bad thing, since every resident brings their own experience (or lack thereof) to the table...

8:43 PM

Blogger A girl said...

This comment has been removed by the author.

11:10 PM

Blogger A girl said...

I cannot agree more that the system needs a change. Never mind us, medical students, being tired. After all, we are not the ones making final call anyway (thank god for that).

I see post-call residents, with half-empty cups of coffee in their hands, falling asleep standing up all the time. It scares hell out of me because I know that these people were managing patients less than 10 minutes ago.

In fact, if any of the people I care about should fall ill, I will avoid teaching hospital as if it was infected with plague. I will run far far away where there are no sleep-deprived colleagues of mine, even if it means no MRI as well.

11:20 PM

Blogger A Bohemian Road Nurse said...

This is the precise reason why I did not go to medical school. I knew that I would always want a life outside of the hospital, and I figured that shift-work as a nurse was the only way to accomplish this.

7:08 PM

Blogger Vitum Medicinus said...

Man, that reminds me, I need to read House of God

10:51 PM

Blogger Couz said...

I wouldn't really recommend reading HOG. I found it harsh and demoralizing, and paints a really outdated picture of medical training.

9:40 AM

Anonymous Anonymous said...

...and none of the resident union rules apply to medical students such that we may work 30 hour plus call shifts, 100 hour work weeks and up to 3 weeks straight without a full 24 hour period off (from my own experience in a recent internal medicine rotation anyways)...

1:54 PM

Blogger Liana said...

Couz, there is hope...

Where I did medical school (in Canada), peds was trying a new system of floating call, where the senior residents took turns working from 8 PM-8 AM for a certain number of consecutive weeks a year. The rest of the year, each resident would be doing 1 in 4 call, but only from 8 AM-9 PM.

At least, that's how I understood it, but it was explained to me by a resident who was on call while I was on call so my memory may be a bit fuzzy.

At the same time though, I have to admit that as a rural family resident in Alberta, I find our new contract makes it hard for me to learn as much as I should be learning. Hmm, perhaps a subject to be expanded on in my blog if I get around to it.

11:57 PM

Anonymous Anonymous said...

Hi, thank you for your blog entry. I have to comment on "Europe : 60hrs/week". I am an intern from europe.Sure officially in most european countries there is an restriction like 60 hrs a week. BUT: e.g. in Germany residents work like 80 hrs as well, but are paid only 40-60 hrs a week... that is the difference. please don't think europe is a paradise regarding working conditions for physicians. in some countries the docs went on strike last year...

1:13 PM

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