House Calls

Medical and other musings of a plastic surgeon

Are we mollycoddling new physicians?

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Today’s Sentinel posted an article about new rules regulating the hours that young doctors in training can work. It rescinds the previous limit of 18 hours straight and allows 24 hour shifts. Over the years, I have watched with growing alarm from a distance as the issue of how hard doctors work has played out in the media and in residency training programs.

 

All medical doctors, upon finishing medical school, must do a residency in some specialty approved by the American Board of Medical Specialties. This is the only route to board certification by a specialty board approved by the American Board of Graduate Medical Education. Residencies range from three years for Family Practice and Internal Medicine to six years for plastic surgery and seven years for neurosurgery. All residencies require that doctors in training work long hours and take emergency call in a hospital at night. Most require overnight shifts. In addition to the working hours, residents must constantly read and study on their own. It can be intense.

 

When I trained in general surgery, a common call schedule was every third night. On those days, if I went into the hospital at 6 AM on Monday, I did not go home until 6 or 7 PM Tuesday. There was no guarantee I would get any sleep in that 36 hour period. Wednesday, I worked a full 12 hour day. Thursday, I repeated the cycle. In seven days, this translated to a work week of between 100-120 hours. Yes, I was tired, sometimes exhausted but so were all the other residents with me. We were not left to our own devices, however. We always had more senior residents over us and above them were our attending surgeons, all watching over us. I made many errors while in training, but I honestly cannot recall a patient who was harmed simply because I was tired. Perhaps I am rationalizing, but I really can’t.

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Even then, viewed through a fog of fatigue at times, I knew that my skills and judgment as a surgeon advanced the most when I was on call. I was more connected to how my patients were doing. One of my pleasures was making evening rounds in the hospital then going back to a patient’s room to chat with them and their family. Over the years of training my decision making skills improved until, as a senior resident, I was essentially managing, and operating on patients on my own and assisting in training those coming after me. When I left my residency in general surgery at the U.S. Naval Hospital, Oakland, CA in 1984. I felt ready to go out on my own and practice independently as a surgeon. I believe my subsequent years bore that out.

 

Today, one of the laments I hear continually from my surgical peers is that young surgeons are leaving their residencies with insufficient experience to practice independently. Many come under the tutelage of a more senior partner in what amounts to an additional year, or more, of informal apprenticeship. I have heard directly from residents in training that they don’t feel they are getting enough hours of direct patient care because of the restrictions on how long they can work, restrictions which, ironically, are as often ignored as they are followed. Residents do not clock in and out, despite the work hour restrictions and I have it from some who are presently in training that the present work hour restrictions are followed more in spirit than in fact, because that is the reality of patient care.

 

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I am not one of those curmudgeonly old doctors who follow the dictum, “I suffered through it so others need to do so as well.” Times change. Fewer doctors are going into solo private practice these days opting instead for large group practices and hospital groups where they have shorter hours, less administrative burdens, paid vacation, 401K retirement plans, and a built in network of peers to cover for them so that their nights on call may be no more than a few days a month. I was on call in private practice every night for the first four years and have been on call every other night for the 24 years that followed. If I have to stay up all night doing emergency surgery, I still have to be at my office in the morning to see a full day of patients, or perform elective surgery safely and properly. My training prepared me for that.

 

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I am not questioning the dedication or desire of young physicians or saying they have to suffer because I suffered. I just know that medicine seems to have segued from a calling, both unique and sacred, to just a profession like any other. We are now “providers” or “vendors” and not physicians. Nurses and physicians assistants, with a fraction of our time in training and experience keep pushing out their scope of practice to become ‘de facto’ providers and vendors themselves. What hasn’t changed is that, In medicine, complete strangers allow you into their lives in a manner more intimate than in any other profession and often literally put their lives in your hands, and all because you have two letters after your name. The only thing I can think of that comes close is the bonding between soldiers in battle. In medicine, we are at war too- against disease, decay, and death. I think this calls for a little sacrifice of our comfort and even a little loss of sleep now and then.

 

Doctors on the front lines of patient care and dedicated to their art will always view hourly restrictions established by bureaucrats, academicians, and politicians with mild contempt and derision. Let’s hope the doctor in whose hands these clueless individuals place their lives in some day doesn’t work on a strict 9 to 5 schedule, or bail once his or her allotted hours for the week have been attained.

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