June 10, 2020
[Previously published July 15, 2019]
For the better part of a century at least, it had been the usual practice to work graduate doctors undergoing specialty training continuously for three to five years on a duty-cycle typified by 36-hours on, 12-hours off, and every other weekend on duty.
In a recent article in the online medical magazine, Medscape, a study was reported that showed that capping the work hours of medical residents at 80 per week and 30 in any single shift in 2003, had not resulted in any increase in hospital mortality, readmissions or cost of health care for hospital patients.
From my perspective at 84, and retired for almost 20 years from a three-phase practice — family practice, board certified 17 years; Occupational and Environmental medicine for 11; then a psych residency and ten years of state hospital forensic psychiatry, I am inclined to view what has been the standard model for residency training as a cycle of (inner) child abuse, perpetuated by those who were themselves abused.
Following a year of “rotating internship” and the first of three years of an orthopedic residency I was just beginning my second orthopedic year with a rotation at a San Francisco hospital less than five minutes door-to-door from my home hospital, where my wife and three kids were living in a hospital-provided apartment. In addition to the apartment my pay was $3,000 per year.
In the first week of the rotation another ortho resident, who lived across the city, had been reluctant to come in to the hospital at 3 am for some relatively trivial problem, so the duty staff orthopedist made the rule that residents would remain in the hospital whenever on call. No matter that the rotation hospital was smallish and calls were few and far between.
However, this meant that the next time I was on weekend call, beginning at 6 pm on Friday, I would not see my family from Friday morning to Monday evening after work. Call was every other weekend.
The ortho Chief at that hospital was out of town. The orthopedist who made the rule was unyielding. Two weeks later my wife called on Sunday to tell me that she was putting the kids in the car and leaving.
Instead, I called the Chief of the residency and resigned on the spot, thinking I was “finished in this town” for doing so. Instead, on Monday morning, my Chief recommended me for a job in a local group practice, saying that when he was young he had faced the same choice, and that he had made the opposite choice, which he later came to believe was the wrong one, due to the resulting estrangement from his family.
A few years later that brilliant orthopedic surgeon, though I know nothing more of the details, sat down against the trunk of a eucalyptus in the park at Presidio San Francisco and shot himself to death.
I believe very strongly in the value of continuity of care and good medical training. I do NOT believe that we need to keep young doctors on duty constantly in order to achieve it to a sufficient degree.
I believe that if more experience is needed to teach a skill, then we might keep people in training longer WITH REASONABLE AND LIVABLE PAY AND ACCOMMODATIONS in order for them to acquire it. And at the same time give them sufficient time each day to rest and recharge in the bosom of family.
To any who object that such a scheme would be unaffordable, I say that how we allocate resources is a choice a community makes. For too long, corporate pirates and government kleptocrats have exploited the benevolence and high ethical standards of physicians to maintain a level of excellence in medical care for which they have never been willing to pay fair value.
And physicians, upon repeatedly experiencing that no good deed goes unpunished, have sunk in to the sadness of children long betrayed and abused. They suffer a very high burnout rate and the highest suicide rate of any employment group
I weep for my colleagues, who will not, it seems, make use of the power they possess to regain control of their profession.
There is a very interesting theme common to the arguments of those who favor residents working virtually unlimited hours. It manifests the logical fallacy of the excluded middle: “Either residents must work unlimited hours or they won’t learn anything and there will be no continuity of care for patients”.
This reminds me of the way individuals with Cluster B Personality disorders tend to see the world in polarized, over-simplified, all-or-nothing terms. Looked at from a slightly different angle, denying residents, (trainee-doctors), a healthy emotional and family life also resembles the “pervasive pattern of disregard for the rights of others”.
Seen from that perspective, the system at its worst has been flagrantly antisocial towards its victims, however willing those victims may have been. Residents have been like the abused spouse who is pathologically unable to set a boundary with the abuser, much less leave him or her. Like other victims of abuse, residents still believe that if THEY can just do everything right, everything will be OK.
I have recently arrived at a theory about the state of our government, which seems unable to resolve a single problem because of the incessant need of its representatives to fight with one another and for each to prove their opponents incapable of proper parenting. I’m thinking that we have managed to elect a “critical mass”, pun intended, of Borderline Personality Disordered persons. It doesn’t take many Borderlines to paralyze any human community or organization.
It is depressing to think that our own profession has had so little insight into the pathological origins of its flawed teaching methods that it sees no other choice but to persevere in them.
Having ended forty years of medical practice and three separate medical specialty board certifications with a final decade of training and practice of psychiatry, and having continued to read the journals for an additional 20 years in retirement, I am more than ever convinced of a lack of congruity between the way the brain learns and the organization of medical education. Learning and memory formation not only benefit greatly from periods of rest and sleep, they utterly depend upon them. There is reason to suspect that we have become learned doctors DESPITE some of the ways in which we have been taught.
Since it is obvious that no resident could possibly attend every patient continuously from the beginning to the end of every episode of ill health, and, because of this, perfect “continuity of care” by an individual is impossible anyway, therefore it seems to me that a need for compromises should be acknowledged, such that, say, a TEAM could insure continuity, while its individual members were able to get enough rest and sleep, and were able to be with their families in a healthy way.
Personally, I think that for senior members to give up the systematic exploitation of younger members would only enhance our profession. As for scavengers like the hospitals, insurance companies and government, shame on us for having allowed them to feast on the minds and bodies of our young.
In the 1970’s, what had been called the medical care system was suddenly called the health care DELIVERY system, as though anyone could “deliver” it. Soon thereafter cheaper substitute personnel were employed to “deliver” it and physicians were devalued.
The thing that defeats physicians is that they are so ethical that they can’t figure out a way to withhold services in a group action. In which they have also been impaired by the laws against collective action by individual practitioners. When California Medical Association (CMA) physicians plotted out the relative value of services in order to help docs figure out what each service and procedure was worth, it was called the Relative Value System (RVS). The federal Fair Trade Commission charged the CMA with “conspiracy in restraint of trade”. With no funds for legal defense the CMA agreed to recall all the RVS books. The categorization number for each service and procedure, developed for the RVS, became the basis for the Current Procedural Terminology (CPT) system, and was afterwards required to be specified for each charge to any insurance program, including Medicaid and Medicare. One set of actual relative value charges, calculated by multiplying each service’s relative value by a modest dollar dollar conversion factor, was hijacked by the California workers’ comp system, which set that price list as the minimum charges for those services. Then, a couple of years later, those minimum fees were set by the state to be the MAXIMUM charges a physician could bill the state system. Thus in California, the physicians’ useful ideas were stolen by government agencies who then turned them against doctors after forbidding doctors to use them for their own benefit and convenience.
Aside from the use of force, the only power any person or group has over another, is to withhold its labor, knowledge and services. If physicians were able to do that in concert at strategic junctures, it wouldn’t take long before they were back in charge of every aspect of medical care where medical ethics, knowledge and training are essential. Ironically, doctors are “hoist on their own petard” of conscience and benevolence. Modified strikes could even be accomplished without withholding critical medical services to patients, though some elective services might need to be curtailed from time to time.
But organizing docs is like trying to herd cats. The very characteristics that cause them to accept the abuse heaped upon them by the system — the need for love and approval, or the converse, the abhorrence of the slightest disapproval — will likely prevent them ever from saving their profession from ruin through thoroughly unscrupulous political and economic contamination.
There is no evidence that the abusive aspects of residency training serves any useful purpose beyond the very limited lesson that perseverance in the face of fatigue and adversity is possible.
END