On a New Model Residency

Sep, 2019

My daughter just completed her intern year at a family practice residency in Pittsburgh. Unfortunately, it proved to be the same sort of unnecessary hell that I experienced 23 years ago. Despite so-called reforms in limiting hours worked that began in 2003, the intern is still overworked and stressed close to the breaking point. This works to the detriment of these young doctors and their unsuspecting patients who have no idea of what is going on behind the scenes and its negative impact on care and in-hospital error. The worst part is that it destroys the joy in medicine that motivates a good physician; the profession then just becomes a job like any other – done for the money. Once dashed, it is hard to recover that enthusiasm. The hypocrisy is obvious. For our patients we preach good sleep and exercise, but residency programs are designed to make both difficult, if not impossible. Most residents gain weight out of anxious eating and become addicted to caffeine trying to stay awake in a state of constant exhaustion. Some die or kill others when they fall asleep while driving home.

The average family practice intern works about 60 hours a week with some weeks closer to 80 and some closer to 40 depending upon the rotation. The hours are far worse in surgical residencies. This work is often carried out in the face of inadequate support and training, and sometimes under criticism that is not meant to be constructive. A malevolent tradition of hazing still exists in medicine as it does in the military, certain sports, fraternities, etc. The hazing creates an atmosphere of fear that undermines unconventional thinking and impedes development. Important questions go unasked. “See one, do one, teach one,” is the slogan you hear, but it is “See one, do one, kill one,” that is the reality that you fear.

The best review article on sleep deprivation in residency was published in the journal Chest in November of 2009. Its findings should have been a wake up call to the profession but there is institutional resistance which I will explain later. It discusses performance issues. For example, 41% of 254 internal medicine residents cited fatigue as a cause of their most significant medical mistake, with a third resulting in a patient fatality. Surgical residents post overnight call were found to make twice as many errors in simulated laparoscopy than after a night of sleep. It discusses morale and life-style issues. The systematic sleep deprivation of residency is associated with depression, obesity, alcohol abuse, and increased mortality from both motor vehicle accidents and suicide.
So why are residency program directors and faculty so determined to prevent real reform? They argue that work-hour limits threaten resident professionalism, education and patient care delivery. They say that this would engender an unprofessional “shift work mentality,” and reduce opportunities for longitudinal training that disrupts patient care. But for the real reasons we need to follow the money. To be continued….

– Gary Gallo, MD