This morning one of my patients was telling me about her recent sleep deprivation; recently retired, she has been going to bed late and getting about 5 hours of sleep most nights. I mentioned to her my own experiences in sleep deprivation, specifically when I was a resident in neurology years ago. I explained how my frequent long work days and on-call nights resulted in frequent sleepiness and fatigue, sometimes to the point in which I dozed during lectures and grand rounds. Her reply was, “How is that allowed, for new doctors to work such long hours? Isn’t that dangerous?”
How much and how long a resident should be allowed to work have long been a challenging issue in the realm of medical postgraduate education, and one not without controversy. Certainly when I was training, there was a pervasive sense of machismo associated with working your white-coated tail off, as if spending every waking moment in the hospital made you superhuman, worthy of admiration and respect. In addition, a certain culture has developed over the centuries regarding the “coming of age” of the young American doctor, “paying your dues.” As academic institutions go, it is often difficult to break such deeply entrenched, longstanding traditions, particularly when the professors have long ago paid their dues. The medical school where I completed my residency was built in 1797, so as one may imagine there were many time-tested, conservative traditions we were expected to follow. Me, I found the training process and the hallowed traditions associated with it absolutely fascinating, and sometimes even thrilling, but there were times (usually around 2 a.m.) in which I really questioned why things had to be the way they were, such as being up all night every third night for months on end.
There’s another oft-overlooked reason why interns and residents have been so overworked, and it is purely economic. In reality, a postgraduate trainee and a training hospital enter into a business partnership agreement of sorts the July following the trainee’s graduation from medical school. The trainee needs the postgraduate education in order to become board-certified in a selected medical or surgical specialty and to practice medicine independently someday in that specialty. The hospital system needs the trainee’s hard work, without having to pay that trainee the salary that an attending physician would command–the polite way of saying cheap labor. There needs to be a consistent, large stable of doctors to make everything run properly at a large tertiary care center, and without interns and residents to do much the work, such large, complex institutions would simply grind to a halt, go bankrupt, or both. And with the steadily declining margins of hospitals in recent years (and undoubtedly more to come), how much a hospital must pay for a doctor’s work becomes an increasingly important consideration.
Understand: I don’t write any of this in a pejorative way. Both trainee and hospital have legitimate needs and they need each other, so the relationship is forged on “Match Day” and it continues until the end of the training. When I first found out my first-year salary as a newly minted intern–$28,500–I was overjoyed, frankly; it was better than paying to be there, like I had been in medical school. With each subsequent year of training my salary jumped by $1000-2000 per year. And through it all I spent countless hours in the hospital, often well over 80-90 hours per week, making my income less than minimum wage. There was no questioning it, no raging against it; it just had to be so. So what gets sacrificed most easily and most commonly in such a system? The trainee’s sleep.
Certainly there is the argument that the trainee’s education would be enhanced by allowing proper amounts of sleep and off-work time, and there is clearly truth to that. However, it takes more than that to change a longstanding, proud institution like American postgraduate medical training; there is much more to consider than the trainee’s education. I recall a general surgery resident friend telling me once that he had fallen asleep, standing, earlier that day in the middle of a case; he just shrugged, knowing there was nothing that could be done about that until he finished his training. I remember myself often struggling to stay awake in the middle of the night sitting in the ER writing up a history and physical, looking at the unoccupied ER bed in front of me and literally lusting for it, wishing I could curl up and get some much-needed sleep before our morning rounds.
In 2003, Accreditation Council for Graduate Medical Education (ACGME) limited work duty hours went into effect, reducing the maximum amount of time allowable for postgraduate training work. Among the policies was a call for an “80-hour weekly limit, averaged over 4 weeks, inclusive of all in-house call activities.” I trained in the early- to mid-nineties, so this change came too late to benefit me and my brethren. I deeply appreciate all of my postgraduate medical training, and I remain very grateful for having had it. I do believe strongly, however, that I would have learned more, and would have been happier, had I been allowed more sleep per night on average.
I lead a very busy life; it’s hard, in fact, to find someone with a crazier life than me. However, I get my 7-8 hours most of the time (I’d be a hypocrite if I didn’t, right?). I find that proper sleep allows me to maintain my very busy life and to enjoy it. And, importantly, I know that most everybody can get their 8 hours if they allow it. Unless, perhaps, you happen to be a young doctor in training.