(After two years, I am almost done with call and most of the abusive practices associated with it so you’ll forgive me if I revisit these topics. I have a certain warmth for them and now that I am drawing to the end, I can give you a well-informed opinion. If these topics bothers you or smack of sedition, please skip this article. If not, read on.-PB)
George Orwell in his classic dystopian novel 1984 invents a nightmarish world where, in the time of Big Brother, the very language was being modified to prevent both the expression of dissent and its conception. In the novel, the Party sought not only to eradicate words that could lead to the discussion of thoughtcrime but to prevent even the possibility of it.
In a similar manner, residents lack the conceptual vocabulary to protest their obvious mistreatment and, because they are unable to frame the debate in any other terms but that of the establishment’s brand of Newspeak, they are reduced to sheepishly shuffling their feet and muttering vague self-centered sounding complaints. Your hospital, for example, may justify depriving you of sleep because some studies show that tired residents don’t jeopardize patient safety. You can cite studies that prove the opposite. But all that can really be proven is that the hypothesis is difficult to prove or disprove and the only result of the debate is that your sleep, a critical component of health, is at the mercy of bureaucrats who are not on your side, would work you (and did, at one time) as much as they possibly could, and will forever justify robbing you of sleep because it is not dangerous for the patients.
The simple and obvious fact that humans need sleep and to deprive them of this is a wrong in of itself (regardless of whether it is safe or not) is never discussed although even convicted felons get their full measure of sleep every night and to deprive them of this is considered a human rights abuse.
The debate is controlled in other ways. Imagine you are an intern in a typical Internal Medicine program pulling your usual every-fourth-day overnight call. Suppose one of your colleagues has his fill of it, successfully scrambles into a less abusive specialty, and decides that since his current intern year counts for nothing at his new program, he will quit a few months early to recover. Your program, following the usual impulses and caring not a whit for their subordinates, assigns his call to the remaining interns and this fellow becomes the enemy, the Emmanuel Goldstein, who is the cause of their suffering.
“We’re sorry,” is the predictable mantra,”But your disloyal colleague left us no choice. There are holes in the call schedule and the rest of you are just going to have to fill them.”
And you hate the disloyal intern and what he did to you. And you are encouraged in this belief. I have heard these sentiments expressed from people who should know better. But think about it. If you were a prisoner in a Soviet Gulag and your entire barracks was punished because one of your tovariches escaped, who is to blame for your punishment and why should his labor quota be divided up among the remaining zeks? Does that make sense, making the prisoners responsible for the injustices committed against them?
Of course it doesn’t. And yet, while most residents could sense this intuitively if they bothered to think about it all, their thinking is cluttered with duckspeak from the medical establishment which not only hides the reality of the situation but sets the conditions of any potential debate to preclude anything but the party orthodoxy.
For the system to change, you need to redefine the terms.
For example, if someone attempts to bludgeon you with “Patient Care” as the debate-stopping, atom bomb of reasons why you are to be routinely over-worked and deprived of sleep, suggest that if patient care were so important, the attendings need to pitch in and pull call and that everyone, from the janitor to the nurses, needs to stay more hours.
The janitors would laugh. They may only have a GED but they’re not stupid and they know when they’re being mistreated.
The fact that your program has bitten off more than it can chew and cannot maintain it’s commitments is not your problem. You are the low guy on the totem pole and are not getting paid to solve the program’s problems. It is actually a leadership problem on the part of the program who are committing the cardinal sin of leadership: Not standing up for their subordinates. The other services clamour for the cheap labor of the program’s residents and instead of protecting you, they say, “Sure, we’ll bravely fill the call schedule with our cannon fodder because, donchaknow‘, we got ’em by the short hairs”
Here is more doublethink from the Party:
Although the hospital receives an average of $110,000 per year for each resident from Medicare and pays you less than half of this, you are a drain to the hospital and the cost of training you far exceeds the Medicare reimbursement. On the other hand if we didn’t have residents the hospital as it is currently configured would grind to a halt for lack of physicians to take care of the huge numbers of patients we are able to run through here because we have so much cheap physician labor to throw around.
Because residents don’t bill for their time, they don’t make the hospital any money and therefore as you are a drag on the system we might as well extract some cheap labor out of you…but please don’t stop performing valuable work for which we will bill, not to mention performing essential duties that we would have to pay two of the lowliest mid-level providers we could find each at least twice your salary to perform…and we wouldn’t get the $110,000 either (which is just gravy).
A physician is ethical in all things and you are expected to be scrupulously honest and never cut corners…but go ahead and lie about your hours because it’s Okay to lie about certain things if we tell you it’s alright.
Black is white if party discipline demands it.