Saturday, November 22, 2008

80 Hour Workweeks

"Well, I start work at 6 am so I get tired early," I said to the grocery store clerk, who had just commented on my yawning.

"So, what, you get out at 2?"


An 8 hour, or even a 10 hour day has become a luxury. I forget how it is outside of medicine sometimes. There are reminders, though. When I exclaimed that medical students can now get to the hospital later, now at 6 am, my parents, unfamiliar with the world of medicine, didn't really understand how that could be "late" to start work. They also don't understand that a shift may last 24 hours. That people who shouldn't be on the road driving a car, are in the hospital working with desperately ill patients. And they don't understand that this is an improvement.

Resident physicians in hospitals are now legally limited to 80 hours per week of work. There are other stipulations, making 36 hour shifts illegal, and ensuring that there is a reasonable amount of time between shifts so doctors don't have two hours to come home, shower and change scrubs, and return to the hospital.

Many attribute the changes to the Libby Zion case. I don't know many of the specifics of the case- but the gyst is that a young woman named Libby Zion went to the emergency room at a New York hospital and was given medication which interacted with a medication she was on, or an illegal drug she'd been taking- I'm actually not even sure why she went to the ED in the first place, actually. But, anyway, she went to the ED, there were some over-sights, and she ultimately passed away. It turns out that her father's a journalist, so the case gained wide recognition. The mistakes and oversights that were made in the ED were eventually blamed on sleep deprivation and long work hours for residents.

Some seasoned Attending physicians look at that case and dismiss Libby Zion as a cocaine addict who has somehow lead to the ruin of modern medicine, but I think, all things considered, that the diminished work week has been a good thing.

There are arguments against it- some argue that by decreasing hours from 120 to 80, interns have now been cheated out of 40 hours per week of learning and others argue that increased patient pass-offs between residents increase mistakes. Those who protest hours regulations don't like to mention the effects of sleep deprivation upon the doctors, patients, or upon those unfortunate enough to be on the roads while fatigued residents are driving home.

But, whatever the root cause, or whatever the arguments are against hours regulations, I am reaping the benefit and am lucky enough to be entering medicine at a time where there is at least an acknowledgement that long hours are bad.

Saturday, November 1, 2008


Sometimes I wonder who's actually crazy- me or everyone else. And sometimes it's a hard call.

My school promotes "civility in the learning environment" which basically means that the dean's office works to ensure that medical students are not hit by flying surgical instruments, launched in an operating room temper tantrum, and that we are not routinely humiliated, belittled, or otherwise abused. The dean's office also works to limit student work hours. Working 100 hours a week, coming to the hospital at 4 am, and working for 36 hours in a row, for instance, is no longer tolerated. We're also supposed to average one day off a week.

The dean's office is going to great lengths to ensure what any other reasonable institution outside of medicine would offer automatically.

Now, there are things in the medical school environment that are difficult but that work. Pimping, for instance, is a term used to describe the Socratic Teaching Method. This is where an attending physician asks medical students questions that they may or may not know the answer to. So, why do we use warfarin instead of heparin in this case? What is this (pointing to part of an x ray)? Is this drug metabolized by the kidneys? Yes? What percent of the drug is metabolized by the kidneys? The questions may go on and on. But when done in a benign manner, a student might feel embarassed about the sudden attention to his or her lack of knowledge on the subject of indirect hernias, in rabbits, but the student leaves with a lasting memory of the significance of rabbit hernias.

Incivility is being purposely humiliated in the absence of any detectable learning or teaching. At worst, it may involve physical harm, although I've never had the pleasure of witnessing this. One incident that has forever embedded itself in my mind involves an attending physician I had the pleasure of meeting during a particularly difficult rotation.

For background, this particular medical specialty rotation took place at Madison Hospital (not the real name). Other students having done this rotation at Madison described it as "the worse experience of my adult life," "miserable," "depressing," and any other number of adjectives commonly used to describe a horrific experience.
Every day I travelled 45 minutes to arrive at the hospital at 5 am to round on my patients and I'd generally get out at around 7 pm, unless it was a "short call" day in which case I'd "officially" be done at 10 pm, although this was often subject to interpretation.

Anyway, one particular attending was about to start a didactic session for the medical students, a bunch of the interns, and a bunch of the residents. There were about 20 of us in all. I made a flip comment to someone about how women's lib and chivalry couldn't co-exist.

Attending: Chivalry and womens lib had nothing to do with one another
Me: (thinking- whoops, maybe that was a dumb thing to say; turning bright red) Um
Attending: But, I'm interested, Emily, what are your thoughts on chivalry?
Me: Uh, sorry! (bright red)
Attending: I think Emily has something to say to all of us about chivalry. Go ahead Emily, you have the floor..
Me: (wondering if my comment was inappropriate, still bright red) uh
Attending: We all want to hear what you have to say about Chivalry. Emily is a big expert on chivalry (gesturing)

Meanwhile I had about 20 sets of eyes staring at me. Someone else tried to say something

Attending: No, I think we should all see what EMILY has to say.
Me: (not sure where to look, everyone's staring; I had NO IDEA what to say so I decided to talk about some things I'd read pertaining to the attending's area of expertise) Well, I was reading some papers about gastric cancer and uh
Attending: No, we're all interested in your thoughts on women's lib and CHIVALRY. Please tell us all how the two are related...

After what seemed like forever, it ended. I'm still not sure whether my comment was inappropriate and I certainly never meant to annoy the attending.

I'm not sure if that counts as incivility in the learning environment, but it was embarrasing, unpleasant, and I afterwards regarded this particular attending physician with some amount of fear.

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