There is No Prize for Sucking it Up

Residency entails long hours. You may as well accept this and prepare for it. Up until very recently however the hours were much, much worse and it was not uncommon for residents to all but live in the hospital except for the polite fiction of being allowed to go home infrequently for sleep. These were the bad old day, only a few years ago, when you worked at the whim of your program with no recourse other than to quit if you didn’t like it.

These kind of hours were insane. Nobody can function on three or four hours of sleep every other day, at least not in something as complicated and intellectually demanding as medicine. As a young Marine I regularly went several days without sleep but while being a Marine requires considerable skill and intelligence, it’s nowhere near as demanding intellectually as medicine. You really do stop caring about things as you become sleep deprived. Everything requires more effort. Concentrating on routine (but important tasks) becomes impossible and it is only the occasional burst of adrenaline that makes functioning as a sleep deprived Marine or a physician possible.

In the old days when most of your older attending were residents, things were considerably different. It’s true that they spent long hours at the hospital but the pace was a good deal slower on the wards as there were both fewer interventions and a much slower turnover of patients. These were the days when the hospital course for someone with a heart attack was three weeks. Today it is usually two days, sometimes even one if the heart cath was done early in the morning and the patient is in otherwise good health.

It is one thing to be on call on a service with a census of patients most of whom are long term and stable boarders, it is another thing to be on call on a service with rapid patient turnover and a completely new census every few days. There is simply more work to do, especially when it comes to admitting patients.

“Admitting” is the process of working up the patient when he presents to the hospital and involves the history, physical exam, assessment, and plan which we discussed in a previous post. It is also as you can imagine a tedious paper-work grind at almost every hospital as previous records are tracked down, numerous forms are filled out (many of them redundant and mainly serving the purpose of lawyer-appeasement) and extensive notes are either written or dictated. It is not as tedious in private practice as the economics of paying a physician to waste time come into play but no such restriction apply at a typical academic hospital. Not only will you shoulder the burden of this work but you will also have to clear every decision through either your upper level resident or your attending.

This is the way it needs to be, of course (I mean except for the lawyer protection paperwork) but as a typical admission on a medicine service can take hours in the case of complicated patient you can see that with the rapid turnover in today’s teaching hospitals a few admissions a night will prevent you from getting any sleep when on call. In fact, most teaching services are “capped” or limited on the number of admissions they can take in recognition that learning is impossible if you are treated as cheap labor.

So I don’t want to hear the sanctimony from the old-timers about how much harder they had it back in the day. Fewer admissions and more stable patients lead to a more stable census and more time for rest. Sorry. The trouble was that as medicine became more complex and demanding, the treatment of residents lagged far behind almost as if it were in a different century. Residents working in modern, high-turnover hospitals were treated no differently than their more relaxed collegues from the fifties and sixties.

After several important papers were published detailing the risks to the safety of both patients and residents from sleep deprivation, the Accreditation Council for Graduate Medical Education (AGCME) mandated that all residency program restrict the work hours of residents to eighty hours per week averaged over four weeks. This is a good start but it’s still only a start.

The fact that many in the medical community think it takes eighty hours per week to train you in a medical specialty reflects the general inefficiency and poor organization of medical training as well as a reluctance of some to let go of old, outmoded methods. Eighty hours is better than 120 of course, but it’s not a pleasant way to spend three to seven years of your life.

Let’s look at a typical Q4 call schedule. This means that every fourth night is overnight call. You will work three 12 hour days. On the fourth day you will work through the night until one in the afternoon (you must be released by this time according to the rules). Since you got no sleep on call your half-day is pretty much wasted as you sleep most of it. You must be allowed one 24-hour period per week free from all clinical duties but sometimes this entails being allowed to go home in the morning after call which means that your day off is abbreviated to 20 hours or so.

You will usually end up working 85 hours a week if not more because some people will not let go of the old ways and as they have no life outside the hospital have no incentive to be efficient or decisive. Your time is not valued in the slightest because anybody who cares is paying the same whether you work fifty hours or a hundred.

The worst thing is that most of your time will be spent wrestling the incredibly inefficient paperwork system which is endemic to every American hospital. You will spend most of your time as an intern filling out some sort of paperwork or another. That’s why they still call your intern year a “clerkship.” Trust me, you will spend the majority of your time wrestling with the paperwork. Important or not, there is a huge quantity of it.

So eighty hours does make for a long week and a long month. It is a violation of an unwritten rule of residency to complain, of course. The tradition is to suck it up and not look weak. Still, it is a lot easier to spend your life at the hospital if you have no life outside the hospital which is more the case than you imagine. I had a third year resident on a medicine rotation who regularly rounded in the evening on non-call nights after every other team had gone home sometimes until seven or eight with me and the medical students as her entourage. The on call team was also in the hospital handling all of the new admits so we weren’t really doing anything. She just was just very dedicated but more importantly had nothing better to do with her time.

Patient care is important. On the other hand if you can’t manage twelve patients on your service from six in the morning until six at night then you have a problem with efficiency. All your over-night orders should be written well before normal quitting time and the nurses are more than capable of following them. The labs will cook without you and all of the consultants have gone home and will only suffer to come for an Emergency, delegating their interns to cover things. The on call team, for its part, is there for Emergencies and to follow a few key items for you which you relate during sign-out.

You can go home already.

The best part was that at the start of the rotation the resident lectured me that medicine needed to be my first priority and family and personal life a distant second. This attitude is incredibly patronizing. It is just a job and like most men of my age and upbringing I take work very seriously. I’ll do what needs to be done but medicine is not the military and it should not be necessary to sacrifice one’s family life to its service. Spending time with the wife and children is not a privilege, a reward, or something for which we have to beg.

So you’re not supposed to complain but I think as more and more non-traditional students matriculate into medical school and then into residency training there will be more complaining as the older you are and the more experience you have outside of medicine the less tolerance you have for chicken shit…which is what a lot of the antiquated customs of residency are.

I think the first thing that needs to be done is to eliminate or greatly curtail call. Everybody deserves to get a good night’s (or day’s) sleep. It should also not be a privilege to get some rest. Some call is pretty benign of course. Urologists pull call but there are few real urological emergencies so they sleep pretty well. Specialties like medicine need to go to a shift system. Either that or have a night float system where one week out of the month you work at night and sleep during the day.

Another thing that can be done is to add to the length of residency training. Maybe sixty hours a week isn’t enough time to train a medicine resident. Medicine is inherently inefficient as it deals with inefficient human beings so a lot of the wasted time is hardwired into the system. Add a year. Increase the pay a little and pay overtime for anything over forty hours like anywhere else.

Research any residency program thoroughly. Talk to the residents when you interview. Get a good idea of the call schedule and the hours because some programs are more benign than others.