Is your surgeon too tired to operate?
Automobile accidents are common among overworked young doctors.
Foreword: I've been thinking about when to publish today's Inside Medicine for awhile. It's not about Covid-19, and right now, Covid-19 is all anyone has time to think about. So, I've been delaying adding the finishing touches on this one and getting it to you. But it's one that is meaningful to me, since I am 5 years out of residency, and train residents now. At its core, this piece is about labor and justice. That's why publishing it now, as Dr. Martin Luther King Jr. Day concludes, feels like the right moment. I hope you'll read this article with that in mind.
A recent study published in the Annals of Surgery found that automobile accidents were far more common among general surgery residents who routinely worked very long hours. Automobile accidents were reported by around 14% of residents who either routinely worked shifts lasting longer than 28 hours or who had less than 8 hours off between hospital shifts on 3 or more occasions in a month. And that was just during the 6 months prior to the survey.
Residents in the middle of their training (2nd-through-4th years) were far more likely than 1st year residents (i.e. “interns”) or 5th year “senior” residents to report crashes or near-misses. That’s scary because the 2nd-4th years of training are key in developing technical skills.
If surgical residents are too tired to operate heavy machinery—a car or a motorcycle—do we really want them operating on us? I sure don’t.
We all know that resident physicians work long hours. But how did we arrive at this system, which I believe to be both toxic and unnecessary?
If surgical residents are too tired to operate heavy machinery—a car or a motorcycle—do we really want them operating on us? I sure don’t.
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Time was that recent medical school graduates who were apprenticed to master physicians literally lived in the hospital where they worked. Indeed, that is why they came to be known as “residents.” During the 20th century, hospitals grew addicted to extracting labor from young powerless physicians (even after they stopped living there). When the public wised up to the reality that patients were dying as a result of the mistakes of exhausted overworked young doctors, fancy commissions were convened. As a result, some rules were changed, and some laws were passed.
At first, hospitals complained that they would not be able to stay in business if resident “duty hour limits” were enforced. When states threw hundreds of millions of dollars at the problem, that did little to shut them up. Flush with money (and convenient exemptions that assured surgical residents in particular did not even benefit from the new reforms), apologists for the old way simply moved on to another justification, this one prettier than the last. How could doctors learn about medicine, they bellyached, if they didn’t “see the patient all the way through?” The notion that “continuity of care” mattered above all else was advanced as the next pretext for perpetuating the system of mistreatment. Hospitals and senior physicians dressed extracted labor up as valor.
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Some sub-fields of medicine followed the new rules. Others, like the surgical specialties frequently either were exempt from the reforms, or were found to be in violation. Surprisingly to some, research completed shortly after the reforms were enacted found that patient death rates did not improve. Nor had things improved by the time a more recent New England Journal of Medicine study was completed late last decade (albeit the studies looked at non-surgical specialties in which manual dexterity and quick thinking are not routinely responsible for “saving the day”).
But, honestly, why were the reforms expected to make any difference in keeping patients alive? A closer look reveals that the reforms were almost predestined to fail, if patient safety was the real goal. Under the reformed system, residents were still asked to work up to 80 hours per week, and they only had to work 24-hour shifts (plus 6 more hours for “education and transfer of care”) every third night. It’s not as if residents working under the reformed system were suddenly adequately rested each day. The reformed schedules were hardly humane. They were just less inhumane than the previous ones.
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Something that has long bothered me is how some researchers have buried key findings that don’t fit the narrative that sleep deprivation is not a big deal. In one major study, researchers administered “psychomotor vigilance tests” (PVT) to resident doctors. Overall, the residents who were permitted to work more than 80 hours per week didn’t test very differently than those who could. So, the authors concluded there was no problem. But when I drilled into the results among residents at the end of 24-hour or longer shifts, I found that the results were indeed far worse. Those residents made well over twice as many lapses on the PVT compared to those on their day off, and 60% more than those taken on the same day as a regular shift. However, because the PVT results were similar when the data from all of the shifts were combined, the statistical signal was “blunted.” (Also, bizarrely, the PVT tests were altered to make it harder to detect a difference between residents who were somewhat tired and those who were extremely tired; the tests were also modified to report findings on a different scale than other studies that had also used the PVT metric; this made it impossible for the casual reader to detect that extremely fatigued residents had performed similarly as mildly intoxicated people had when they had completed virtually the same test in earlier studies conducted by neurologists. But that’s another maddening story for another time.)
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What about the doctor-patient relationship? Apologists for the current system of abuse are eager to elevate what amount to warm and respectful working relationships to some kind of sacrosanct bond. But it turns out the love may be unrequited. It turns out that patients are less attached to the doctor-patient relationship than we doctors are. In one study, a majority of hospitalized patients said they preferred a fresh but unfamiliar doctor to a tired known one. Most patients were far more worried about medical errors resulting fatigue than from transfers of care between doctors. If my parents were hospitalized, my number one concern would be safety. My parents have plenty of friends.
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Can we abandon the current system? Can residents learn to be independent physicians without marathon shifts that lead them to drive off the road into a ditch? (If they do, at least they'll be rescued by ambulance drivers who do not work 24 hour shifts). To my knowledge, nobody in the United States has seriously studied what happens when duty hours are actually reduced meaningfully (i.e. to levels that reflect other professions). Commercial pilots, including first and second officers, are not permitted to fly if they are tired; flights are routinely cancelled for this exact reason. Do we really believe researchers would learn very much by comparing the performances of pilots who worked 13 versus 15 hours per day, 6 days per week? Of course not. We wouldn’t even think it safe to perform such a study.
Indeed, what if residents were suddenly treated like other apprentices in high-stress, high-stakes jobs? Would the world fall apart? Would patient care suffer?
I sincerely doubt it. I find the tradition of excessively long and relentless duty hours to be one of the great shared delusions in medicine. Do we really think that 75 years ago, our predecessors somehow stumbled upon the one and only way to prepare trainees adequately, and that was to defy the human body clock? So much for understanding human physiology. Indeed, the work of a modern physician bears little resemblance to the duties of our 1965 counterparts. Technology means we work faster and accomplish much more. We should stop pretending otherwise.
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Why do we cling to this tired system? I propose two reasons. First, we're “paying it backward.” The logic is that “I had to do it, so they should too.” In fairness, I do not think the inner monologue is so nefarious. It’s more likely a defense mechanism. If we were forced to confront the fact that our own torture was without meaning, the trauma might be too painful to bear. This is classic cycle of abuse stuff.
Second, I think having endured inhumane conditions makes us doctors feel special and important. During my training, I survived several months in the medical and cardiac intensive care units where I was subjected to ludicrously long call schedules. The sickening part is that, yes, I confess looking back on those times with pride. I survived. What the hell is wrong with me? Do I have some variant of Stockholm Syndrome?
I think it's worth unpacking that. What does that pride actually earn me? Nothing, other than pride itself. The logic is circular. And no, the experiences of those long shifts were not terrifically educational, I do not believe. I learned more about ICU care from podcasts I listened to in the gym and “medical journal clubs” than the random extra 12-16 hours I babysat the ICU on those nights.
Now, I did learn a lot as a resident covering the surgical intensive care unit on overnights during my intern year. (My hospital’s surgical ICU did not allow 24-hour shifts from interns.) But that’s not because I was tortured with long hours. Overnight shifts lasted 12-hours. The reason I learned so much is that I was alone in the ICU with nurses and a post-residency fellow doing his sub-specialty training in ICU care. It was not endurance that taught me anything. It was the independence. We could call an attending physician if we needed help. But when it came down to it, we almost never needed to. That was the learning. We could run the show overnight and keep our patients safe. It wasn't about the long hours.
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As you can tell, I am a strong proponent for reducing the work hours of resident physicians. I see it through the lens of justice and I cannot look away from what I perceive to be a hierarchy of injustice. In addition, the current system forces many caring physicians who burn out to leave medicine, therefore serving the community for only a brief time after medical school. Finally, emotionally mature and talented young adults who otherwise might have considered entering medicine may be repelled from the field to begin with. Many of them are wise enough to sort out that the pretty fantasy of the bleary physician giving everything they have for their patients amounts to mistreatment packaged as noble service.
And yet, I am not an extremist. There are certain specialties where punching out on time every day is just not feasible, and maybe even unwise in some circumstances. But these should be rare and occasional, not a routine part of residency. Also, there is something to be said for training to be able to function while tired. (That said, residency prepared me more for parenthood than life as an independent practicing physician). But I submit that the medical field can safely train our successors more humanely than we do today. If we can, then we should. On the occasions when long shifts are necessary, hospitals should pay for Ubers or Lyfts home.
But that begs the question. If a doctor is too tired to safely drive themselves home, should they have been scrubbed into that last surgery?
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Thanks to Dr. Kristen Panthagani for creating the data visualization for this article.