Wednesday, April 04, 2007

The Hours Part 2

I'm on a Q 3 schedule right now and it absolutely killing me. Slowly, painfully. Death by a thousand sleepless nights. Or at least that's how I feel. I'm scheduled to be on call 10 times in the next 28 days. Let's think about that. Thirty hours a shift X 10 shifts and were talking three hundred hours. Now in the real world, the world of forty hour weeks, it would take me 7 and a half weeks to accumulate that many hours. But I'm an intern. My sole purpose is to serve as a cheap source of labor. So that means in 10 shifts, I will work as many hours as it takes a normal person to do in almost 2 months. Does no body else understand the absurdity of this. And during your two months, you will get to go home, get federally mandated lunch breaks, call in sick if you need to. And I will get none of that... not in my ten days.
Old school docs, those who don't support limiting hours will say it's not that bad, you can still get some sleep. I'm working in the trauma ICU. I'm in charge of 16 critically injured patients, by myself, all night long. I don't sleep. I not allowed to actually. This particular ICU was cited recently for not providing interns with a place to sleep at night. So they created one on the 7th floor. Little room that even says SICU intern on the door. Reality check. The ICU is on the third floor and the call room is on the seventh. I'm not allowed to leave the ICU. No matter what. If I leave I'll fail the rotation. So every night at my hospital there is an empty call room with a nice comfy bed and there is a SICU intern who badly needs to lay down. And next time the AMA comes by to evaluate working conditions, my program will point to the SICU call room, and the reps will nod their heads approvingly. But no one will notice the sad, exhausted, depressed intern who will never get to sleep there.


Anonymous said...

This is complete Bull Shit!! What can we do to stop this?? I realize that there are repercussions, but damn it--it makes no sense that they get away with this. I dont understand how programs continue to get away with this. I also don't understand why we as interns/residents can't stop this.

I am thinking of writing a letter to the editor for all the damn major newspapers in the U.S. until someone listens. I know that sounds like some freaking liberal protests, but damn it I am sick of this.

I refuse to believe that there is no way to stop this freaking nonsense!!!!!!!

Anonymous said...

I've been dreaming of learning medicine for years-- I've completed most of the post-bac courses, (I've loved all of them), and have saved a bit of money.

But these all too frequent anecdotes regarding working conditions are why I'm going to wait another year before I make the decision.

I just don't know if it's worth the grief. And it makes me sad..

Anonymous said...

Oh wow, that is soooo awful, what crap!! I feel exhausted just reading about what you have to go through...and the room on the seventh floor...what a joke! I have had to go to the er and am always amazed how nice the physicans are, when I know at least some of them must be interns and residents and therefore totally sleep deprived. Wish there were something I could say or do to help. Thank you for doing what you do and thank you for a great blog, tracy

Anonymous said...

Medschoolhell has postings that made me forget about medical school and yours just reenforce them. I used to be a bit biting at doctors. My dad had done medical research (he helped do the first pacemaker, among other things) and he hated doctors. When I was five years old, my parents had an elegant party and I greeted one doctor at the door with, "So you are Dr. Mike _____, that pompous ass from the children's surgical unit! How does it feel to be God?" (I didn't think I was being bad-- that was how my dad spoke!) My dad didn't hear that and the doctor laughed so hard that he almost cried. He then carried me around with him and his wife and they asked me what my father said about the other doctors which I happily told them. They never seemed to think badly of my dad (he still had a job there years later but this couple liked to talk to me!)and I don't know that he ever knew what I'd said. It was something that I would think of years later seeing my own precocious five year old greet someone at the door!

You deserve way more respect than I'd been taught to give. I was polite, but I was also mean when I got annoyed.

Next time I am in a hospital I will ask more questions. "So, how many hours are you on? Where do you sleep?" I think that patients have a right to know these things. Please know that you are appreciated and when you do these rotations, that somewhere someone is sending out prayers for your health and strength!

Old MD Girl said...

Irishdoc, please tell us it gets better after intern year?

Anonymous said...

And to think that you chose this.

All this nashing or teeth and complaing. Nobody put a gun to your head. As for the debt, you were happy to take it on at the time.

You made the choice and you continue to choose everyday.

Indian Medic said...

i hear u ER doc.
going through pretty much everything u are.
except i dont have a kid to worry about.
hang in there. this too shall pass.

Filet-o-bitch RPh said...

you might like my blog:

Stacy said...

The medical training system in the United States is truly so FUBAR that my girlfriends who work in other fields (and my acquaintances from other countries) think we must have lost our minds here, and they're right.

What really irritates me are the idiots who yap at the exhausted interns and residents after 24+6 hours straight on call to "work faster" and "be more concerned about your patients." "Snap to it, willpower, willpower," they say.

You can no more provide good patient care after 28-30 hours of no sleep and "will yourself" past the fatigue, than you can run a marathon or stay efficient after starving yourself for a week. They did a study which found that post-call interns and residents are well into the range of being legally drunk by hour 17-18 of being awake all night and running around the hospital, and by hour 25 or 26, they're less mentally capable than someone who's been downing 6-7 shots of tequila and grabbing a few beers on the side. And these are the people who are forced to make life-and-death clinical decisions!!! In fact, in the study, it was found that *every* resident, no matter how much they prided themselves on their ability to will themselves past no sleep or to concentrate through extreme fatigue, suffered similar failures in their brain function, and all of them committed both minor and major errors at a startlingly higher rate after being up for so many hours. There is no way to "get used to" sleep deprivation no matter how much one might try.

This is all about economics and everyone knows it-- medical residents are cheap labor, and whenever the hospital admin screws up and expands volume and acuity level beyond what the staff can actually provide, the burden falls on the housestaff. Somehow the USA can go off and spend trillions of dollars in wars in distant countries, yet we don't have enough money to provide half-decent staffing in major teaching hospitals with hundreds of very sick and extremely complicated patients.

What seriously angers me (not to mention my husband, who never sees me these days) besides the hours' effect on me is:

#1 my patients suffer due to my own fatigue and that of the other residents. By hour 22 of being up all night, running around, writing notes, answering 100 (frequently dumb) pages of one sort or another, it's physically not possible to be functioning at adequate capacity, much less the peak "on the ball" level you need to have to be on top of things in a busy hospital setting with dozens of very acute patients. And since most of the ultra-specialized services now like to put these inexperienced, untrained residents on there to do the scutwork for their cases, when it comes time to make decisions or simply to keep track of everything, we have to be on top of hundreds of details that we often don't know much about to begin with at our level of training.

#2 The ridiculous hours and the ever-expanding load pushes most of us interns and residents, who are otherwise very kind, generous, altruistic people to go into medicine in the first place, to become sniping and carping to one another and to the nursing staff. I've come to learn how idiotic it is to talk about people's "personalities" as though they were fixed descriptors, since people's personalities vary so much depending on what kind of environments they're placed in. In the abusive, overworked, understaffed, underpaid, utterly outrageous working environments of teaching hospitals, residents' personalities mutate into often angry, bitter people who aren't effective at patient care and who can no longer function as they used to.

#3 The driving-- nothing is scarier on the road than a post-call intern or resident who's been up all night. A good friend of mine from college years ago got into a horrible accident post-call that severely injured both her and the other driver, and caused so much damage that she was ruined financially. I can't even keep count anymore of the number of times I've dozed off at the wheel after being up for 30 consecutive hours. Once I even ran TWO RED LIGHTS when I dozed off before two close intersections-- by some unbelievable stroke of fortune I didn't hit any other cars (or pedestrians!), but when I finally came to, I realized that I had crossed the yellow line and was veering to the opposite side of the road!

What's unbelievable is that our on-call residency system was apparently starting by some guy at Hopkins a century ago, a crazy surgeon-type who it turns out was a cocaine addict who abused so that he could stay awake for 20+ hours straight doing operations. That's what our residency is based on!

It's only gotten worse despite the bogus "work hours rules" since the volume in hospitals is so much higher than decades ago and the patients are much, much sicker. However much complaining some of the old-school docs make, back in the day, they used to actually sleep on call, usually 5-6 hours at least w/o getting paged. "On call" meant what it sounds like-- you'd be on svc to take care of major emergencies, which weren't frequent, but you wouldn't actually be working a 30-hour shift. Now, "on call for 30 hours" means "working 30 hours straight", aka going against every fundamental aspect of human biology.

The obvious stupidity of this whole system is rarely broached to the public or oversight committees, though our patients obviously can see by Hour 27 that we're not quite "with it" when we talk to them. (And if they do ask me how many hours straight I've been up, I can't lie to them.)

The only instance in which I've heard "whistleblowing" occurred in some program that got extremely arrogant and stupid. The PD at this particular program was a jerk who didn't like one of the residents finishing up, and dallied around without providing him the medical license for which he'd slaved away for so many years, in anything remotely resembling a timely fashion. This is the one truly unpardonable sin of the current system-- to brutally exploit a medical resident as cheap labor for 3 or more years, then turn around and refuse to give them what they've worked so hard to earn. It's also unbelievably stupid on the program's part, since now they've created the most deadly species on Planet Earth: a very angry, trained resident who's worked hard for the program and been screwed over, and now has nothing left to lose.

So this resident, understandably furious at the PD and screwed out of his license, launched a nasty lawsuit and began revealing all the idiotic, dangerous practices that plagued the teaching hospitals (including the working shifts). It was so embarrassing for the hospital that patients began launching their own lawsuits started using the "behind-the-scenes" details, and it caused terrible damage to resident recruiting and efforts to bring in patients to the hospital. The PD finally came to his senses and granted the license, at which point the resident halted the assault and things quieted down.

But without someone being truly screwed over to such an extreme like that with little left to lose, there's just not enough of a push to reveal all the idiocies that lie at the center of teaching hospitals.

Honestly, I wonder sometimes-- should we be unionizing? It may be the only way to protect ourselves from being pushed around and exploited even more as cheap labor.

SeaSpray said...

Hi Irish Doc - You don't post often but when you do-they are excellent. You tell it like it is and you write well.

I am sorry that you all have to go through this. It actually scares me considering the fact that I may have to have surgery and will be in a teaching hospital for the surgery and an inpatient for 1 week. I am considered high risk and that is why my current Doc thinks I would be better served in the teaching facility over our community hospital. He wants me in a place that has a urology wing and where docs are on call 24/7.

Admittedly, after reading this stuff I am a bit unnerved and confused.

I also remember you saying don't be a patient in a teaching hospital in May or June because that is when the monkeys run the asylum and in another blog a med student said don't be a patient in May, June or July for the same reason.

Does anyone care to shed some light on this. Is there anything that can reassure me about going there?

Ultimately - it's in God's hands. :)

Alyssa said...

I like to cite these facts to people who look at me like i want to be a doctor for the money and luxury. When I first read the Intern Blues the intro was talking about the newly passed regulations on how long interns can work. You'd honestly think with as many times as they beat it into you to provide people with the best possible care, that after 20 hours without sleep I have a hard time caring for the people I already love!

The Lowly Worm said...

European law now limits the number of hours UK docs can work - hospitals have to try to keep us to 48 hours a week max. But we're concerned we're missing out on valuable on-the-job training as a result... Where do you think the best compromise lies?

chrisdw said...

Irishdoc, I really enjoy your blog. Well, maybe enjoy isn't the right word. I think it is informative and well written. I am writing you to ask if you would ever recommend medicine to anyone. I am a 22 year old pre-medical student who is already burnt out from school and research. I am planning on taking a year off before medical school but it is always something that I have wanted to do. I cant imagine doing anything else but at the same time I cant imagine going through what you are going through and not completely freaking out.

Analise said...

Good words.