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Time To Care
PREFACE: How many hours should a doctor work? How much sleep is important for responsible decision making? How important is learning by marathon on-duty hours? These issues hit the headlines in recent years after some notorious mistakes by physicians in residency, subsequent lawsuits, and eventually a 2003 regulation by the Accreditation Council for Graduate Medical Education (the body that governs residency training) that residents can work no more than eighty hours a week—a foreshortened workweek for many. Today, residents are unarguably more rested, but handoffs from one resident to another in hospitals are more frequent and confusing. Liz Gaufberg, an internist, psychiatrist, and professor, writes of her life as a resident before the duty-hour restrictions were put in place and provides a vivid picture of hazards of the Herculean workday. Janet Gilsdorf, an academic pediatrician at the University of Michigan, reflects on the damage done to patient care, physician learning, and a hospital’s workforce (and finances) by the circumscribed hours. Their debate—and insights—go to the heart of what it takes to build a physician.
THE FIRST-YEAR RESIDENT wore a sour expression and a rumpled white coat as he presided over my husband’s recent admission for a serious illness. With the faint blush of sunrise just visible though the hospital window, I suspected that our brusque young doctor hadn’t been horizontal for many hours. Was he eyeing my husband’s bed jealously? Perhaps. But with the morning sun he was sure to find respite and a bed of his own. Residents like this one are now limited to working no more than eighty hours a week. In any given shift they may work a maximum of twenty-four hours of continuous duty, plus an additional six hours for patient care follow-up and education activities, such as lectures. These standards were put in place by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 to acknowledge the scientific evidence that long hours and sleep loss have a negative effect on residents’ performance. But not everyone likes the new resident "duty-hour" regulations. Opponents in the current debate on resident duty-hour reform might raise concerns that the discontinuity created by this resident’s departure and a new resident’s arrival would increase the risk of medical error. The resident himself would lose the privilege and educational experience of following the course of my husband’s illness. Indeed, many opponents of duty-hour reform offer vivid and heroic examples from their own internships in support of maintaining the former status quo. Thirty-six-hour shifts with twelve hours off, repeated again, and again, for weeks at a time. Each admission—dozens some nights—was a high-stakes case to be cracked. These doctors were exhausted, yes, but still primed for each new learning experience, any opportunity to breath life into the medical texts. Each encounter brought them closer and closer to when their white coats ceased to feel like a costume donned for some life-or-death stage play and became a second skin.
THEN THERE ARE TALES MORE LIKE MINE. Almost twenty years ago I served as a first-year resident on an every-other-night intensive care unit (ICU) rotation in which I cared for patients much in the same manner that the impatient resident cared for my husband. "Every-other-night" meant arriving for rounds at 7 a.m.; working through the day, night, and most of the next day; going home to eat and sleep; then returning the following morning to do it all over again. We beginning residents actually preferred the every-other-night ICU rotation to the every-third-night ward rotation because, quite frankly, we found ICU patients to be more manageable than ward patients. They were, after all, continuously monitored by the high-tech machines of the day and high-level nursing staff. ICU patients rarely wandered down the hall to shoot drugs in the bathroom of our public hospital. They were typically too short of breath to tell long-winded stories in response to a simple yes/no question, and, in any case, all the "important" data were right there at the bedside, bleeping from monitors and neatly packaged on nursing flow sheets. Daily, I would reduce my ICU patients to a litany of numbers and organ systems in my progress notes. I developed an efficient system for recording each patient’s pulmonary-cardiac-renal-nutrition-disposition information. I’d remove the previous day’s note from the three-ring binder of the chart and set it side-by-side with the nursing flow sheet, copying data quickly, only stopping momentarily to shake my cramping hand. I learned that these notes were very important—perhaps the most important thing I did—for they were what the attending physician reviewed to see what kind of doctor I was becoming. During this time, I was so tired that as I walked the three blocks home from the hospital to my apartment I would look at the sidewalk with its pebbles and cracks and imagine just lying down there. I could lie there all day, pedestrians stepping over and around me, the sun warming me in summer, a gentle snow covering me in winter. I could just lie down and sleep and sleep. But somehow I kept putting one foot in front of the other on the sidewalk until I got home and collapsed on the unmade bed, white coat and all. As we gobbled Chinese food out of plastic washbasins swiped from the utility room, my fellow first-years and I shared our admiration for those senior residents who were "walls," blocking admissions coming in through the emergency department (ED), and disdained the "sieves" who allowed bogus admits to pass through to torture us. This is how we sometimes thought of our patients, as direct obstacles to sleep and nutrition. We did our best to help and support each other—that is, until one of us called in sick one time too many, which sometimes was just once. Calling in sick for anything other than a life-threatening medical emergency could, overnight, make you a persona non grata among your peers. We were spread that thin. All throughout my ICU rotation, I found myself humming that song from the Wizard of Oz—the one that begins, "I would while away the hours, conversing with the flowers..." I couldn’t get that one out of my head. I realized that it was because Bob, the rotund and affable ICU nurse, hummed it all night long while adjusting vents and tubes. Then I recalled with a sudden start the rest of the lyrics—"if I only had a brain...if I only had a heart"—and laughed until tears sprang to my eyes. My outlook wasn’t always so dark. Sometimes I found myself at a patient’s bedside, my hand resting on his or her forearm just above an IV site, chatting with the ones who could talk, just sitting with others. Once I gathered an extended family in the conference room to deliver the terrible news that their loved one had just passed away. I allowed for silence, responded to questions, made empathetic statements—just as I was taught in my "giving bad news" training session—but didn’t feel what I thought I was supposed to feel. The family thanked me anyway.
AND THERE WAS THAT ONE NIGHT, THE TURNING POINT. The usual ICU rotation rhythm was a night with little or no sleep, followed by a night when we could sleep what we called the "sleep of the dead." It was a little tickle that broke the cycle, tipped me over the edge. A feather at the very back of my throat, postnasal drip probably, threw me into coughing spasms as soon as my head touched the pillow on my night off. Several desperate slugs of Nyquil didn’t help, just made me groggy. After the second sleepless night, I slogged through my next shift, hacking and nauseated, nodding off intermittently at the nurses’ station. Then, miraculously, at 3:47 a.m. my bleary eyes scanned the ICU and could hardly believe what they saw. The lights were dimmed, the monitors faintly beeping and blinking. Every patient was stable, all notes written. I realized that I could get a full three hours and thirteen minutes of sleep before morning rounds. Tickle or no, I would, I knew, sink deeply into oblivion. As I retreated to the call room, a page blared overhead: "Anesthesia stat to the Emergency Department!" This could mean only one thing—a cardiac resuscitation code was being called on a critically ill patient. If the patient survived, he or she would be brought to the ICU—and be my next admission. But then a simple thought occurred to me, some possibility of respite, some chance to still get those three hours of sleep. The patient might die. And a dead patient would go to the morgue rather than to the ICU. I said a silent prayer that the patient would die and retreated to the call room. I lay down knowing that my beeper might sound any minute, calling me to the ED. Within a few moments I sat bolt upright in bed. The beeper hadn’t sounded, but something inside me had. I sprinted down the hall and down four flights of stairs, to the ED where the code was just being called on an eighty-nine-year-old female nursing home resident. The patient had died, and I realized that something inside me almost had as well. At that moment, from some deep wellspring inside me, came a pledge to never forget what I had almost lost. I went back up to the call room, finished the rest of the Chinese food, and slept for nearly three hours before rounds started. And I never forgot, at least not completely. There were many other moments in residency that challenged my compassion, my humanity. Most of them occurred when I was soul-numbingly tired. But somehow I was always able to remember and hold that moment as a terrible touchstone—that moment in which I wished a patient dead. During my second year of residency, I mustered the energy to work with our house-staff union to achieve a small but significant change: eradicating the practice of scheduling resident outpatient clinics on the day following an overnight call. Our progressive hospital voluntarily instituted additional changes during the years leading up to the 2003 ACGME ruling. Full disclosure: I have occasionally caught myself uttering the phrase "when I was a resident..." in response to house-staff complaints about current hours and work conditions—but I wouldn’t turn the clock back on anyone.
OF COURSE RESIDENCY REFORM IS NOT JUST about reduced hours. Medical culture exposes trainees to a myriad of role models and rituals, and we quickly learn to adapt or risk losing acceptance into a society that we have long dreamed of entering. Full reform will involve reframing our professional role as an integral part of a team of caregivers, with effective hand-offs essential to the process of team care. It will involve actively cultivating the concept of patients as people; people with needs and fears and hopes, who are embedded in family and community. It will allow adequate opportunity for residents to reflect and renew. I know doctors who are able to maintain composure, grace, and a humanistic perspective no matter how fatigued or overworked they are. I would maintain that their numbers are few, and that everyone has a breaking point. I also know physicians who are cold and impassive even when well-rested. Fortunately, their numbers are also few. The vast majority of us are socialized through the unwritten rules and customs of our training environment into the type of physicians we ultimately become. Duty-hour reform is just one opportunity to take a humanistic stand, just one opportunity to begin to combat the negative effects of what’s sometimes called medicine’s "hidden curriculum" on our resident physicians. In a 1927 JAMA article, the preeminent physician and medical educator Francis W. Peabody stated that "the secret of the care of the patient is in caring for the patient." In the ongoing debate about duty-hour reform, we can’t forget that the care of the patient ultimately depends on the soul of the doctor, on his or her ability to care. In the growing of doctors, we will reap what we sow.
Liz Gaufberg (elizabeth_gaufberg{at}hms.harvard.edu) is an assistant professor of medicine and psychiatry at Harvard Medical School in Boston, Massachusetts, and the Cambridge Health Alliance in Cambridge, Massachusetts.
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What Happened One Night
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