In the interest of full disclosure, I should admit at the outset that I don’t have any basis for comparing anything to fraternity hazing. I wasn’t in a fraternity, so any impression of what pledges go through to join is pieced together from mediocre movies and a few observations of others during college, plus a few hints from friends who were in one. Perhaps it’s a really lovely experience, full of heartfelt chats over soothing cups of chamomile tea. However, as far as I can tell, it’s a lousy, unpleasant ordeal, meant to instill some kind of loyalty to the institution inflicting the punishment for those who make it through.
I remembered a similarly unpleasant loyalty-building exercise of my own when listening to a report about new rules for residents at Maine Medical Center the other day. The change came in response to new guidelines from the Accreditation Council for Graduate Medical Education, which governs how residencies are run.
Shifts of 24 hours, with a further six hours tagged on for followup work, were not uncommon for first-year residents to endure–until now. New rules drawn up by the Accreditation Council for Graduate Medical Education have just come into effect nearly halving the maximum number of hours that medical residents in their first year can work in one shift.
Like previous years, they’ll still be working up to 80 hours a week, but no shift can be longer than 16 hours. The aim is to cut down on the number of medical errors made due to fatigue and sleep deprivation. Dr. Tom Gearan is the residency program director for internal medicine at Maine Med.
“What they’ve done is really look at changing the paradigm of residency education, where traditionally the first year of residency has been among the toughest year,” Gearan says. “So we have our least-experienced residents sometimes working the longest hours. And the ACGME really felt that the first-year residents really should be more structured and supervised when they come out of medical school, and then over the years of training that they gradually increase their hours.”
My residency was relatively benign, as far as sleep deprivation went. We had a night-float system, with one team covering the day shift and another covering nights for a week at a time. We had occasional long (24-hour+) shifts, but they were infrequent. Even so, I remember being so tired after long shifts or a particularly arduous week of nights that it felt like I was walking through pudding as I made my way home. I was well-aware that other residencies (whether for other specialties within my own hospital, or at other institutions) were much worse, and was grateful enough that mine didn’t inflict more suffering.
I’m not quite sure what I was meant to learn during those long, poorly-supervised stretches that couldn’t have been taught in a less draining manner. The real reason for the slog that is residency is two-fold. First of all, hospitals need to have physicians present at all times to deliver patient care, and residents are an inexpensive way to keeping the place staffed. This is a legitimate need, and meeting it does require longer hours than attending physicians are usually expected to put in. I’m much more iffy on the second reason, which is to instill an attitude summarized by the following exchange:
While he can see the sense in the new rules, Dr. Parker is nevertheless glad to have earned his spurs under old system. “Following in the footsteps of some of the older physicians who’ve actually done these long hours, you know I think there’s a certain pride in doing what these older physicians have done, even though the hours were very hard and challenging.”
Tom Porter: “Like a badge of honor?”
Ryan Parker: “Exactly.
In other words, hazing. Get the snot beaten out of yourself for a few years, and at the end you’re a real doctor.
To which my reply is an obscene gesture that doesn’t translate well into blog form. Suffice it to say that jeopardizing patient safety by giving bleary-eyed residents charge over complex medical decisions is a craptacular way of fostering some rarefied notion of true doctor-hood. You learn to be a doctor by being a doctor, not by achieving some feat of strength. You can’t “learn” how to function on too little rest, you can just endure it.
Every physician has to have a first day on the job. Whether those first days are particularly dangerous for patients is an open question, it seems. But first-year residents are going to be stressed enough by the demands of all that they will be expected to learn and do without expecting them to do it and learn it on insufficient sleep. “I had to make it through” is a poor rationale for continuing a dangerous practice for those that come after us.
From what I understand, the loyalty is not to the institution as much as it is to each other. The bonds you forge together will last a lifetime.
So chug, chug, chug, chug, chug, chug, chug, chug, chug, chug, chug.
My wife’s experience is that residents do not necessarily come out of the experience with close bonds. There’s the doctor who shirked his duties so that he could watch the kids while his wife tended to her little catering business. There’s that other one who decided half way through that she didn’t want to do obstetrics anymore and so everyone else had to take on her call load. Then that other one who… you get the idea. Then there’s the fact that everyone is tired and cranky and pissed off and saying things that they don’t mean. A lot of grudges. The fellowships were similar, though she did get a lasting friendship from there. This may be atypical, though, because of the Mormon factor. The Mormons were all buds and it was divide-and-conquer with the rest.
Oh, residents probably don’t.
Less beer.
I have long thought that…
Granted, I’ve not quite expressed it that way but I haven’t earned the right to be quite so sour about it as you have.
The Maine Med guidelines are less bad than the outright hazing for which medical residencies are infamous. But it’s still up to 16 hours a day and 80 hours a week for at least a year, and that still sounds pretty grueling. That’s more than I would want to work — I’ve worked that much when circumstances have demanded it, but I don’t believe that kind of effort is sustainable for more than a few weeks at a stretch. The mental fatigue, if not necessarily the physical fatigue, will still diminish the ability of a newly-minted MD to deal with the handiwork of the local Gun And Knife Club, the pukey kids with anxious parents, and the cardiac arrests that will be pouring out of the ambulances during the graveyard shift in the E.R.
Certianly a new doc should be able to handle stuff like that, but it still demands time and concentration to get it right and not make a mistake along the way. That’s pressure and stress. A human being needs a day off work, a weekend, to get some relief from that. If you don’t get it, you’re eventually going to crack. While the program sounds like it will produce fewer errors, Maine Med is still going to crack some young docs. Is that the point — to weed out the ones who will crack easily?
Russell can correct me if I’m wrong, but it doesn’t seem like they are big into weeding people out, once you’re in medical school. According to Clancy they would bend over backwards to help people get through med school. They’d already invested quite a bit in them and didn’t want to lose that investment.
There was one person that was kicked out of her residency. I think about her sometimes. $200k in debt for a career that she will never be able to go forward with. The kicking out was a formality, though. She had a mental breakdown. Ended up getting psychological help and then used her undergrad psychology degree to become a therapist. That is that last I’ve heard of her. It was an unfortunate situation and I think a trigger that residencies are loathe to pull. Then again, more selective residencies may do so more casually.
It depends a lot on the medical school and residency. It’s true that most have sunk enough into you that it’s worth their while to try and keep you in. Some are more apt to jettison under-performers than others, and I seem to recall a legend some residencies (typically on the surgical side of things) that actually had fewer spots for senior residents than interns, so you weren’t guaranteed a spot in coming years just because you’d been admitted to the program.
There have been a lot of these issues going through my head recently and I’m about ready to burst with a really long rant (and start asking every doctor I know if anybody is hiring doctors that think 70-hour workweeks are unreasonable and don’t think the problem is that Dr. Wife was “the one who chose to get married and contemplate having children”). The ubermensch ethos among doctors has been taking a huge toll in the Truman/Himmelreich household lately.
Calming down… calming down.
Ahhh, yes, residency. My wife started the first year with the national regs. Oddly, the attending staff said that they’d never seen residents so tired. The 80/30 cap merely resulted in working 80 hours every week running back and forth between endoscopy and obstetrics rather than 90 one week and then 70 the next with more consistent rotations. The following year they figured out how to rearrange the schedule to work the same 80 hour weeks but without reeking quite as much havoc with the constant expectation of having to be two places at once.
The older doctors, of course, scoffed at the 80/30 cap and talked about how easy they had it. Then, when they rearranged the schedule, my wife and her peers started talking about the newer residents in the same way. It was all hell. The possibility that there might be a better way made it worse than just a hell… it made it a pointless hell. So they hold on to their scars and think to themselves, there must have been some benefit to it all. There must have been. The divorces, the turmoil, the missing of the early lives of their children… it couldn’t have all been unnecessary. Could it? Could it? No, it couldn’t. It couldn’t! they must have gotten something that these newbies are missing. Thank god for the scars.
But what’s particularly frustrating to me at the moment is that the effects last beyond residency. The mentality results in the work culture of doctors that make those that would choose to work part-time into freeloaders. It results in the deification of the doctor who worked for 18 months without ever leaving town and thinking any doctor who insists on using her vacation time as spoiled.
It sets the pace. It makes doctors make damn sure they are well paid for their work after all that they endured to get there. It reduces empathy. It robs them of their life outside of work, making it that much easier to not pick it up again (and, in turn, demand the same of other doctors). It makes it more difficult for women doctors to find husbands so that they may marry their work.
Well. As I said, I’m particularly excitable about all of this at the moment. Right now about half the doctors coming out are women, but they’re still outnumbered in the profession and particularly in areas of influence. I hope that they can set this right. Or we’ll get out of this place and she will get out of this job and I’ll discover that we’re in an anomaly.
I plan to write more extensively about this in a later post. In the meantime, for you personally let me assure you that there are decent, humane medical jobs out there (I’m very happy to have landed one). You have my sincerest wishes that your wife is able to find one.
I don’t understand why >80 hour weeks and >16 hour days aren’t standard for newbies in other professions, like airline piloting. Shouldn’t they have the same opportunity to bond with their peers?
You know, > 80 hour workweeks for your first year out of college followed by a 32 hour workweek for your second year might go a long ways towards stabilizing our freaking labor market.
Because after that second year, lots fewer people would be fans of “working hard” over “working smart”.
I had 55-hour workweeks my first job out of college. I can’t decide whether it helped put things in perspective or whether it simply set my pace. At my last job, my boss had to tell me “Good lord, son. Go home!” But it does help me appreciate a 40-hour workweek.
My wife, on the other hand, still hasn’t recovered from residency/fellowships. It’s like she has six years of sleep-deprivation to catch up on. The Sandman never seems to be satisfied. It’s as though she feels the need to sleep any time she can catch it, having spent so much time not being able to catch it. Though that’s kind of moot right now, since she is on call in one form or another four days a week and actually has to catch sleep when she can.