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Narrative Matters

Dolores

Dolores had been barely six months into her family practice residency training. As a new family practice faculty member, I wondered how we missed the warning signs. Suicide risk factors were certainly present—new employment, isolation from family, a stressful work environment, chronic sleep deprivation, considerable student loan debt and service obligation, and a spouse also in residency training. But thousands of residents year in and year out endure the same training and pressures without tragic outcomes. At the time—the situation has since eased somewhat—the stress and long hours of residency were a rite of passage, a boot camp that once completed assured privileged membership in the medical profession.

Wondering whether other residents in our institution’s training programs shared Dolores’s risk profile, I conducted a survey of all first-year residents. A high response rate (85 percent) showed that residents were keenly interested in the subject. The survey revealed that trainees working more than eighty hours a week were much more likely to have suicidal thoughts (22 percent) and be depressed (47 percent) than those working fewer than eighty hours (9 percent and 27 percent, respectively).

Hoping to prevent another tragedy, a few months later I presented the data at a hospital executive committee meeting. Several department chairs asked who would pick up the slack of patient duty if residents’ work hours were reduced. The hospital CEO questioned the data’s validity and commissioned the Arthur Andersen consulting firm to do another study—one that deleted annoying-to-management questions about depression and suicidal tendencies. Naïvely I had believed that Dolores’s death and the compelling data would catalyze change. I had much to learn about hospital inertia and economic barriers to reform.

Overwhelming Strains

 
My interest in changing the physician training system was spawned by my own and my wife Krista’s prolonged internship and residency experiences, Dolores’s death, and my institution’s resistance to reform. I didn’t know Dolores well but shared some of the same stresses of residency training. For example, when she was a fourth-year medical student, Dolores had not "matched" in family practice—meaning that through a computerized lottery process, an available residency position was not found for her specialty. She therefore followed her spouse to New Mexico and hoped for the best. In our fourth year of medical school in 1984, Krista and I unsuccessfully competed in the couples’ match program. Unmatched, we scrambled to find programs that hadn’t yet filled all of their training slots. Rather than residing in different states to pursue our preferred specialty residencies (hers in OB/GYN, mine in family practice), we chose to accept internal medicine internships at the same hospital.

To train in our desired specialties, in 1985 Krista and I went outside the computerized lottery system and obtained positions on our own. This move required a second internship. At that time, interns’ work hours exceeded ninety per week; we were granted one day off a month and two weeks of vacation a year. Like Dolores and many other two-physician couples, we had large debts. We’d delayed purchase of a home and car and had to start paying off loans during residency. It was exhausting to work long hours and a struggle to scrape by, paycheck to paycheck. We didn’t have a day off together for the first six months.

On a rare free evening together during our second internship, Krista shared some shocking news. On her way home from the hospital that day she had considered slamming the car at high speed into a tree. She was exhausted and depressed and felt that she was a bad mother to our then one-year-old daughter, Shannon.

We discussed the "microsleeps" that we experienced when driving home after thirty-six-hour shifts without sleep. We talked about how much longer it took us to read electrocardiograms and interpret fetal monitor strips when we were so sleep-deprived. It was like swimming in molasses.

One night on call, a nurse paged me to the ICU to replace a partially obstructed endotracheal tube in a patient on a ventilator. It was 2 a .m., and I had been soundly sleeping in the call room. Dutifully I tried to replace the old tube with a new one while the nurse manually oxygenated the patient and talked me through the procedure. But in my muddled state I could not thread a new tube over the metal guide. Fortunately, a second nurse’s frantic page brought help from a senior resident, saving the patient an emergency tracheotomy.

A Different Approach Needed

Top Overwhelming Strains A Different Approach Needed What Works Doing Good For All

 
I have witnessed disciplinary actions levied by residency programs against intoxicated or substance-abusing residents, presumably to prevent medical errors. Yet hospitals permit, even encourage, sleep deprivation and long shifts for residents, despite growing evidence that these also are harmful to both residents and patients. When investigating errors, hospitals do not usually collect data on physicians’ or nurses’ work hours and shift lengths. Yet it seems logical that overwork and sleep deprivation can easily contribute to medical error.

Recently, the Occupational Safety and Health Administration (OSHA), the American Medical Student Association, and the Committee of Interns and Residents advocated federal regulation of residents’ work hours. The regulations limit these hours to eighty per week, provide at least one twenty-four-hour off-duty period each week, and curtail shifts to a maximum of twenty-four hours. (The Accreditation Council for Graduate Medical Education, or ACGME, instituted voluntary "work duty" guidelines in 1988, the year Dolores died.) In June 2002 Sen. Jon Corzine (D-NJ) introduced legislation to make regulation of residents’ work hours a condition of a hospital’s Medicare participation. The legislation coincided with the ACGME’s report that recommended new limits on residents’ duty hours—limits that were approved by the ACGME’s board and will take effect in July 2003.

These calls for change are needed. But despite my residency experience, I am ambivalent about some aspects of reform. The rigors of residency training build a solid foundation by combining critical medical knowledge with practical clinical experience. Following a seriously ill patient through a twenty-four- or thirty-six-hour course is a time-honored educational opportunity that would be lost with the proposed regulations. The intense training experience tests a resident’s mettle, resolve, and intellect and teaches self-reliance and independent problem solving.

I remember at the beginning of a thirty-six-hour ICU shift admitting a sixty-year-old woman with congestive heart failure due to severe mitral valve disease. Her condition quickly deteriorated, and she was rushed to surgery, where her mitral valve was successfully replaced. To admit the patient, follow her through surgery, and leave the next evening knowing that we had saved her life was intensely educational and gratifying.

Another factor in my ambivalence about completely changing the status quo is residents’ substantial contribution to physicians’ workforce capacity. Decreasing residents’ work hours could reduce access and services for poor and vulnerable populations served by this sector of the safety net.

But there is a price to pay for taking no action. When a resident commits suicide or when disturbing trends of increased substance abuse, suicide, marital discord, and depression are identified in the medical profession, reform is imperative—for the safety of both residents and patients.

A career in medicine is like a long-distance run—the pace must be measured and planned over a thirty-to-fifty-year haul. Recent data suggest that during residency many physicians learn work habits that injure and impair them, result in premature death or retirement, or destroy marriages and other relationships at alarmingly high rates. Too much is crammed into residency training, while too little is invested in lifelong learning. Residency is not like staying up all night studying for a medical school exam. Doing that may have been enough to pass the exam, but the information is quickly forgotten. It may once have been possible to learn everything during residency training. But the exponential growth of medical knowledge and technology requires a radically different approach to physician education.

For example, physicians could supplement traditional lecture-based continuing medical education (CME) requirements with practical "mini-residencies" to enhance clinical skills and use new technologies. At our institution, field faculty precept medical students and residents, who, in turn, keep these rural educators informed about what is available online through the center’s library. Some of these preceptors have learned clinical skills such as colposcopy through these mini-residencies, or attended through the department’s inpatient teaching services to keep their hospital skills sharp.

After surviving my own protracted residency training and that of my wife, and after training many residents and witnessing trainees’ impairment and death, I still believe that there are ways to reform residency training without eliminating important teaching moments or reducing safety-net capacity.

What Works

Top Overwhelming Strains A Different Approach Needed What Works Doing Good For All

 
As educators, we should better identify residents who are struggling and provide effective support, intervention, counseling, and mentoring. There are signs to watch for: poor evaluations, scarce attendance at resident meetings, disorganized medical records or oral presentations of patient cases, failure to answer pages, lengthy disappearances during the day, and concerns expressed by other residents. I remember one resident who exhibited several of these signs; it turned out that fellow residents suspected possible drug abuse. An intervention was arranged, and the resident received appropriate treatment. We should consider adapting or codifying proposed regulations of resident work hours. While the old, voluntary ACGME guidelines were ineffective, the newly proposed regulations may be too prescriptive. For example, a thirty-six-hour shift without sleep might be allowed, as long as it is followed by an enforced rest period. Being in house in a nice call room while answering a few pages and sleeping for six or seven hours (a relaxed scenario that occurs with some specialties at certain nonbusy times of the year) is not the same as working all night delivering babies. Yet the proposed regulations would simply count duty hours and not allow flexibility across specialties.

The larger problem, of course, comes down to money. It will be difficult to wean our hospitals and training programs off a cheap, overworked resident workforce. Hospitals receive from the federal government’s Centers for Medicare and Medicaid Services about $70,000 a year per resident. Residents’ stipends and fringe benefits average $46,000. If residents’ work hours shrink, calls will likely be made to extend residency training by a year, reduce stipends, or eliminate moonlighting by residents. But with the average debt among medical students exceeding $100,000, such measures will surely make things worse for the potential Doloreses among young residents and exacerbate the downward trend in medical school applications.

How to finance such reforms in the residency system is considered the biggest sticking point, but it need not be so. Perhaps Dolores would not have chosen to kill herself if she had received an average stipend of $37,380 for forty hours of work a week in a fifty-week year and if her overtime hours, defined as forty-one to a maximum of eighty a week, could have occurred either in the training program or by moonlighting. If her overtime had reflected fair market value for physician services ($50–$75 per hour), she would have had the resources to reduce her student loan obligations—easing some of her terrible stress. Such calibration also would reduce hospitals’ temptation to exploit residents.

Doing Good For All

Top Overwhelming Strains A Different Approach Needed What Works Doing Good For All

 
Incorporating moonlighting into a residency education program can be a win for all. As an upper-level family practice resident, I moonlighted on weekends by providing locum tenens (practice relief) coverage for a doctor in a community health center in Questa, New Mexico. That work provided a stress test that taught me what I was well trained for and what I was not. (As a result, I arranged elective rotations to enhance my electrocardiogram and suturing skills.) It also permitted me to earn enough to pay off our credit card debt.

In 1993 I helped to create at the University of New Mexico School of Medicine an academic locum tenens program emphasizing practice relief in rural and medically underserved primary care practices. These are mainly located in the twenty-nine New Mexico counties that are federally designated as having shortages of health professionals. In April 2002 the program had a record month, providing the equivalent of 300 days of primary care practice relief. Demand across the state, including in the Albuquerque area, calls for more than 500 days per month. Many, many community health centers, Indian Health Service clinics, public and private hospitals, urgent care centers, emergency departments, and private physicians are willing and able to pay fair market value for residents’ time. Getting to know residents also gives these institutions a crack at recruiting them to their community after graduation. (Our locum tenens program is the nation’s largest and oldest of its kind, but a few others exist, such as those at East Carolina University and the University of Kansas.)

Medical students, residents, and physicians in practice too often sacrifice a healthy balance between personal and professional activities. It is not altruistic to work more than eighty hours a week for our patients if by doing so we poorly manage them or sacrifice relationships with our own family and friends.

Dolores’s journey in the medical profession ended prematurely and tragically. I hope that the latest calls for reform in the residency education system will chart a different course that allows residents to learn at a more rational and measured pace than current long work hours and sleep deprivation permit. The training regimen should be more balanced, more relevant to our lifelong vocation, and more respectful of students and resident trainees. Neither residents’ lives nor those of their patients should be put at risk because physicians believe that they are immune to the effects of long work hours or sleep deprivation. They are not.

The stakes are huge. After all, any one of us or someone we love could be on the receiving end of a medical error committed by an overworked, stressed-out resident. And I never want to get another phone call about a resident’s suicide.

Editor's Notes

 
Daniel Derksen, Dderksen{at}salud.unm.edu, is an associate professor in the Department of Family and Community Medicine at the University of New Mexico (UNM) School of Medicine. He is director of the UNM Center for Community Partnerships and principal investigator for the W.K. Kellogg Foundation’s Community Voices initiative to improve health care services and access for uninsured and underserved populations in eight New Mexico counties.

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