Workaholics Anonymous

As a physician trained in the US I can testify to the grueling work hours during my residency training. It can take a toll on your health, your personal life and above all quality of medical care imparted to your patients.

A recent story in Washington Post titled “A Case That Shook Medicine” points to one such incident. ((http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html)) A father lost her daughter within 24 hours of an emergency admission. The father later found out that the residents working that night had been on 36-hour shifts. According to the Washington Post article:

“Zion’s anger was exacerbated by what he learned about the hospital’s staffing on the night Libby died. “You don’t need kindergarten,” he wrote in a New York Times op-ed piece, “to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call — forget about life-and-death.” In addition, Weinstein, the intern assigned to Libby, was covering a large number of patients; Stone, the other resident, was never awakened; and the supervising physician, Sherman, wasn’t called when Libby deteriorated.”

However, instead of bracing fatalism the father of the deceased child decided to do something about it. The article continues:

“As a columnist for the New York Daily News and a friend and confidante of many journalists and power brokers in the city, Zion vented his outrage about the state of medical education widely and loudly.
Over time, the image of the bedraggled, unsupervised intern wreaking damage in hospitals would be featured in the pages of The Washington Post, the New York Times and Newsweek. One overtired intern, interviewed on TV’s “60 Minutes,” obligingly forgot one of Mike Wallace’s questions.
In May 1986 Manhattan District Attorney Robert Morgenthau agreed to let a grand jury consider murder charges. Although it declined to indict, the jury issued a report strongly criticizing “the supervision of interns and junior residents at a hospital in New York County.”

His efforts resulted in what we call the Bell Commission recommendations.

“In 1989, New York state adopted the Bell Commission’s recommendations that residents could not work more than 80 hours a week or more than 24 consecutive hours and that senior physicians needed to be physically present in the hospital at all times. Hospitals instituted so-called night floats, doctors who worked overnight to spell their colleagues, allowing them to adhere to the new rules.”

It took ACGME another 14 years to enact countrywide standards. It is ironic that the biggest opposition for this sort of reforms often comes from senior physicians. According to their argument long work hours are needed to get the necessary experience and insight into honing medical skills. One of the factors that impede learning is the break in continuity of care, according to them. I remember that during my training at a university hospital all the residents were “encouraged” not to mention certain facts in their annual JHACO evaluations. That especially included the fact that we were being paid according to a 40-hour work week when in fact some of the residents were especially those in ICU and Surgical floors were putting 90 plus hours per week sometimes.

At the heart of this problem are as usual, economic forces. Residents are cheap labor. Moreover, the government pays the teaching hospitals a fixed amount per year to train residents. If the residents are allowed to work the usual 40-plus work weeks it may not be economically feasible for training hospitals to fill in the night floats with regular physicians or physician assistants. It may be a while before we can all come to a consensus on what entails optimum schedule for the residents.