6.30.2009

Presumably, they also use paddles

In addition to the various political blogs that I troll for material, I've started reading more written by other doctors. I think this started when I wrote my Jim Carrey piece for Ordinary Gentlemen, but since then I've kept it up. A particular favorite of mine is Respectful Insolence, and I've more recently discovered Skeptical OB.

The author of the latter, Amy Tuteur, made reference in her latest post to a spot of trouble the Massachusetts General surgical residency training program has gotten into recently. It seems that they are not abiding by regulations limiting residency work weeks to 80 hours, and have been cited by the Accreditation Council for Graduate Medical Education. From the Boston Globe:
Junior surgeons at Massachusetts General Hospital have been working too many hours, in violation of patient safety rules, according to a national accrediting organization that is threatening to put the hospital’s surgery training program on probation.

The Accreditation Council for Graduate Medical Education cited the hospital because a significant number of its surgeons in training, known as residents, were exceeding hour limits and working seven days straight. The organization believes these workloads contribute to fatigue-related mistakes, and has given the hospital until Aug. 15 to fix the problem.
Now, to me this is a good thing. While the surgeons produced by Mass General are assuredly top-notch, beating the crap out of them with grinding shifts seems an unnecessary part of the experience. Surprisingly, Dr. Tuteur differs:
I recently read that the prestigious surgery training program at Massachusetts General Hospital is in danger or losing its accreditation. It's not because it has failed to properly train surgeons, or because of mistakes. The program may lose its accreditation because the trainees, also known as interns and residents, have worked more than the maximum of 80 hours per week. The hospital seems to have clearly violated the rule, but I find myself strangely ambivalent about both the rule and the punishment.
She goes on to describe her own experience of being crushingly, dangerously tired, including the following hair-raising anecdote:
My most notable transgression while sleep deprived, though, was when I began hallucinating during surgery when I was one of the surgeons. It was a relatively minor case, and my role was simply to assist, but I kept forgetting where I was and talking to people who were not there. This resulted in gales of laughter from everyone else in the operating room. When the case was finished I was allowed to go home early (5 PM) since I clearly could not be trusted to care for patients.
To me, minor role notwithstanding, she was clearly too tired to be caring for patients in any capacity, and this is a pretty striking indictment of her work schedule as a resident. Oddly, this isn't how she sees it:
The system was brutal in the extreme … and yet. And yet it taught me to be a doctor, to take complete responsibility for someone else's life, and to never give up, no matter how long it took, until the best possible result was achieved. It was drilled into me that the patient came first; my comfort: my hunger, my tiredness was meaningless. All that counted was what the patient needed.
I... do not agree with this. I think Dr. Tuteur falls into the same nostalgia trap that other doctors who were trained under similar circumstances do, which is that they somehow conflate the brutality of the training with their attachment to their profession. "We went through it, and it made us who we are," so to speak, "so you go through it, too." This is merely a justification for institutionalized hazing, which is what much of residency really is. (That, and cheap, abusable labor.)

Plus, while Dr. Tuteur thinks much of the medical errors that we ascribe to doctors can actually be pinned on nurses, pharmacists, etc, let's not kid ourselves that hunger and fatigue are "meaningless." As Spartan and stoic as that sentiment may seem, it is also manifest balderdash and empty bravado. Your fatigue does matter, and putting off rest until some vague benchmark of clinical success is acheived merely inculcates the misguided belief that doctors are heroic miracle workers instead of normal people doing their best. If people aren't allowed to drive trucks without getting sufficient rest, I really can't imagine why residents should be expected to function safely while similarly fatigued.

My residency, which actually did comply with regulations limiting my hours, still made me incredibly tired after working a 24 hour+ shift. I remember being so tired going home that I felt like I was moving through pudding. And, rather than making me a more committed doctor, it simply made me surly and unyielding. The tasks that stood between me and sleep didn't feel like something I was doing for my patient, but came to feel like barriers to the rest I desperately needed, and merely made me resentful. (Perhaps these were simply defects in my character coming out, but being chronically sleep-deprived didn't help.) Residents at Mass General can learn to be superlative physicians without a training program that is dangerous and inhumane.

No comments:

Post a Comment