The wickedly wild, wacky world of American medicine is chockfull of some seriously curious traditions. We certainly learned that fact early in our career. Consider the goofy ritual of nurses and medics using alcohol swabs to “sterilize” needle injection sites. We’ve all known for 40 years that plain ‘ol soap & water is better. We still bow & pray at the altar of alcohol. Kinda like . . . you know . . . winos.
Or, think about the fact that there are fewer places in a hospital where you are more likely to catch a nosocomial cootie, than from a doctor’s shirt sleeve, necktie or stethoscope. When’s the last time your physician treated you in short sleeves – as pretty much any infection control nurse on the planet can tell you they should?
Or . . . or, here’s one of our favorite maniacal medical missives: blood draws from the inner elbow. That particular part of the human body is called the antecubital fossa. (yes, it costs a lot of money to be able to talk like this) Of course, it also happens to be one of the most painful places we can stick a needle into you, other than maybe, your private parts. And because your elbow might bend when you jerk away from the stab wound, the patient is very likely to screw the blood draw procedure up entirely. In which case, guess what? Yep. They stab you in the other elbow.
You see, phlebotomists could simply be taught to use what’s called the “intern’s vein” just above the wrist, which hurts a lot less and is easier to find. That’s what Paramedics do. But that would make far too much sense. So they don’t.
But not one – not one – of healthcare’s bizarre rituals is any more wacko, than the profession’s demand that student doctors must work jaw-droppingly long hours in teaching hospitals each week, as residents in training. Within the hallowed halls of health, “residents” are the highest level of students. They are already doctors because they have papers verifying they finished med school. And they do indeed get paid a salary, which works out to be just about $6.00/hour. So what is their reward for completing the grueling 4 years? Well, these newbies are forced to suffer thousands of impossible hours each year because, well, that’s what the oldies had to endure. And if they had to do it back in the day, well by God, the youngins’ will just have to “man up” and do the same.
Of course, by that mind-bending stab at sandbox logic, we should all still be churning our own butter, too.
It is a fact that the torturous residency schedules in most medical schools can and do stretch well over 100 hours a week. That’s typical medical school religious dogma. It’s been going on for decades and is not likely to change as long as the ‘old guard’ is running things. Any serious discussion of real change in residency protocols, sparks heated debate between those who would deign to shorten work shifts or ensure more time off between shifts – and those who react in horror to any tampering whatsoever with tradition. It is a topic which pits respected healthcare institutions – such as the Harvard School for Public Health and the American Academy of Family Physicians – to name just two – against each other.
Now, back in 2003 a landmark change occurred, when the Accreditation Council for Graduate Medical Education (ACGME) made the decision to limit the number of hours that student doctors could work. They capped work time to “only” 80 hours a week. Of course as a bizarre compromise, it was still totally acceptable for training hospitals to enslave residents to stay on duty 30 hours straight, with no promise whatsoever of sleep time.
4 years later, in 2007, the U.S. Congress spoke up about this insanity, urging the Institute of Medicine to launch an investigation. Not a bad idea. They wanted to know if there was a link between the ungodly student doctor schedules and patients getting maimed and killed, by such goof-ups as medication errors due to doctor mental and physical exhaustion. The IOM’s findings were published in 2008, and stated that in order to ensure patient safety, there had to be increased supervision and regulation of residency work hours.
In 2011, the ACGME squeezed a bit more. They said medical residents in their first year could be ordered to work no more than 16 hours straight. Second and third year residents can work 28 hours in a row. But the time in between shifts was cut from ten hours to eight. So these young doctors – already stressed to the max by the sheer weight of new responsibilities – are very often walking, talking drug-pushing zombies, treating patients, one after another, while napping on hallway gurneys.
Never mind the changes that teaching hospitals were ordered to put in place. In doing research for our book, “The Paramedic Heretic” we spoke with 71 student doctors across the country. Nearly all told us how they were routinely instructed by their senior residents to simply lie on their time cards and put down the “legally expected” hours – not their real hours worked.
So we decided to take a closer look at the debate that rages quietly within teaching hospitals.
The Argument for Shorter Shifts
Those who want serious changes in residency hours tend to be passionate that current practices increase both patient harm and, ultimately, the communities they serve.
The strongest argument against these inhumane schedules – other than the fact they are illegal in any other workplace in America – is the deterioration of physician performance due to mental and physical fatigue. Doctor Chris Landrigan of the Harvard School of Public Health – an expert in the subject – believes that residency shifts should be capped at 12 hours and that longer shifts are both ridiculous and dangerous:
“This matter of slave-labor is not based on science. The evidence is clear that you can’t learn how to handle sleep deprivation. It’s ill-conceived.”
Landrigan believes that OSHA should step into the fray because of the danger it poses to student doctors themselves, let alone dangers to patients. And multiple studies have indeed shown that residents who are chronically sleep-deprived are at a higher risk for motor vehicle accidents, sharps injuries like needle sticks and mental health issues. In the long term – well after they graduate and go out on their own – lack of sleep also puts these medical professionals at higher risk for obesity, diabetes and heart disease.
The IOM report in 2008 concurred with this opinion, and noted that “scientific evidence shows that human performance begins to decline after 16 hours of wakefulness.” They called for an elimination of shifts exceeding 16 hours. They referenced studies which found that after 24-30 hours without sleep, cognitive abilities drop dramatically. Another study involved 2,700 student doctors, who documented their shifts; hours of sleep; workload and what, if any, patient medication errors they had made. The study revealed that when the residents lacked sleep, they were seven times more likely to make mistakes resulting in patient injury or death.
You’d think there surely ought to be a law, right? You’d be wrong. The governments of cities, counties, states and federal – are totally intimidated by the juggernaut called healthcare. Which goes a long, long way toward explaining why they ignore the fact that healthcare kills more Americans every week, than were killed by the collapse of the World Trade Center. Yes, reality bites, doesn’t it?
The Argument Against Shorter Shifts
Those who oppose shortening residency schedules are adamant in their conviction that the current system is the best one. They cite “tradition” as well as the need for doctors to learn how to deal with long hours and a physically demanding workload that may follow them for most of their career. Of course when you ask how many veteran doctors they know routinely stay awake 30 hours straight, you get a lot of blank looks, because the reality is, almost no physician does. It’s science fiction.
Another argument which many doctors and teaching hospitals give to justify long shifts, is what they call “better patient outcomes” because of continuity of care. They note that physician hand-offs (when a physician transfers a patient to another at the end of a shift) are a dangerous time in hospitals, as mistakes (such as failure to report lab results) can easily be made. Longer resident hours, they say, help minimize this problem and increase the needed continuity.
One of the biggest cheerleaders for these residency nightmare shifts is the CEO of the ACGME itself, Doctor Thomas Nasca. While he acknowledges that the schedules are tough, he also believes that the danger to patients is minimal, since at this stage the residents are “closely supervised” by more experienced doctors. Thus, even if a resident did make a medication error due to fatigue, he says, there are safety controls in place to catch mistakes before they can harm patients.
Hooey. We went through our own internship at UCSD La Jolla. On our busiest shifts we were rarely “supervised” by anybody.
So our comment to Doctor Nasca would be this: Choosing to hide your head in the sand regarding patient safety is immoral. And what exactly is your response to the other studies: One study showed interns who work 24-hour shifts, are more than twice as likely to crash their cars on the way home from work, than those who work 12-hour shifts?
Are you even slightly aware how many thousands of MDs admit they are prescription drug abusers? How much of that mind-bend is the result of the way they were trained?
Your support for traditional, “macho medicine-men-in-training” goofiness is straight out of Bizarro World.
So what’s our take? Simple: start over. For just once in your life, pay attention to what other nations’ doctor training programs are doing – the European Union, for starters. For more than 100 years, we’ve been training doctors to work on us with sharp objects without sleep, and yet we have – surprise, surprise – failed to produce super-humans. Instead, we’ve created a medical culture that encourages severely sleep-deprived, impaired physicians to take care of millions while – incidentally – killing and maiming hundreds of thousands. On what planet in the cosmos does this make sense?
Adequate sleep is a fundamental physiological need. No amount of caffeine or “alertness training strategies” can replace closing your eyes and planting your head on a pillow.
There is no logical reason to believe that 100-hour workweeks build a better doctor. Would it build a better airline pilot? Think about that, the next time you plunk yourself in your seat on a jetliner with your little bag of pretzels. Or, the next time you schedule a surgery.
It ain’t rocket science.