Residency work hours and striking a balance
A businessman often entertained clients by taking them out to dinner at gourmet restaurants. When he was travelling, he often relied on fast food chains for his meals. He knew this was an unhealthy lifestyle, but it really hit home when he went to his annual physical exam, and his doctor told him his cholesterol was far too high and he was at risk for diabetes due to his weight. “But I have to continue this lifestyle,” the businessman insisted. “My business depends on me being available to my clients and impressing them at our meetings.” “That’s understandable,” his doctor told him. “But your body needs good, healthy food and exercise. The good news is, you can train it to work differently. I suggest you spend the next few years eating a breakfast of sausage and eggs, a lunch of hamburger with extra fries, and whatever you like for dinner, as long as it adds up to about 700 calories. Keep the fat content high when you can. This will train your body so it knows how to react better when you are traveling for work or going out to client dinners.”
This conversation only seems absurd until you realize that many doctors actually believe that the body can be trained in this way. Which leads us to the controversial topic of sleep:
“Yes, more mistakes happen when doctors don’t get enough sleep, but I actually perform better with the adrenaline.”
“I finished residency before the 80 hour rule was in place, and working around the clock better prepared me for the unexpected late-night cases that come up.” “If working fewer hours means extra years of residency, I choose to take the risks and be done sooner.”
There is plenty of research that shows the risks of performing tasks without adequate sleep. There are even studies that show a person’s ability to learn is impaired when they are tired, to the point that they can’t recall the information as well. Emotions about medicine aside, most people would choose a well-rested doctor (or pilot, or bus driver, or teacher) for themselves or their loved ones. However, like most things, it’s hard to take your own feelings out of the debate. The problem is that medical training depends on exposure to as many different scenarios as possible. A doctor must be present to learn. After 8 years of undergrad and medical school, there are lots of bills to pay, there’s retirement to catch up on, and most people have some things they have put on hold until after training – having kids, buying a house, traveling, etc. In order to have well-trained but well-rested residents, residency would have to be extended, which nobody wants.
There is also the issue of no hour restrictions at all for attendings. What happens when a resident finishes residency in a specialty that regularly requires work weeks of longer than 80 hours? They must then learn to perform well on more hours without the safety net of residency, which puts them at a bigger risk financially and professionally. Doctors in these specialties would come out of training unprepared, regardless of the number of years.
Then you look at the impact on the doctor’s personal life. This is where things start getting even more complicated and debatable. He or she chose their profession, so how much should they be willing to sacrifice to practice it? Is it unreasonable to expect them to be an involved parent? Should family vacations be planned based on the ability to return to the hospital unexpectedly or at least to be available via phone at any time? These are more issues of life/work balance than sleep, but often sleep is the easiest corner to cut. As I was told in high school, “There are good grades, friends, and sleep. Pick two.” Requiring fewer work hours can go two ways. The new intern hour restrictions have caused many programs to implement more night float months or weeks, and interns have fewer weekends off to spend with their families. If hours are cut too much, residency will need to be expanded to prepare doctors for their jobs post-training, resulting in more years of life being “on hold”, even though the work environment is more pleasant and more conducive to learning. Is the doctor (and his or her family) entitled to a balanced home life? Or is it expected that they would sacrifice time with their spouse and children for the greater good of protecting their patients’ health? I have great respect for doctors, knowing the training they’ve been through. I am confident that they are prepared to take care of me and my loved ones. However, I think the myth of training one’s body to perform outside of physiological abilities needs to be retired. If a doctor isn’t comfortable with his or her ability to take care of a patient due to lack of sleep, admitting that should not be perceived as weakness. Teaching doctors to recognize symptoms of sleep deprivation and having backup plans in case a doctor needs a break should be a part of all residency training. It comes down to striking a balance for the residents. Too many hours puts them at risk for not learning adequately or making errors that could damage their career, but too few hours leaves them unprepared for the attending years. For those in or finished with residency, what has been your experience with the “right” balance of hours? Did your spouses seem to function well, or did you learn to live with a zombie on some rotations? If your spouse works more hours in attendinghood than in residency, how was the transition for him/her?