Please ACGME, Leave Our Work Hour Protections Alone

By the end of my first 24-hour shift (but more like 28 hours if we’re being honest) in my third year of medical school, I’d seen two C-sections, and that’s as much as I remember. I’m not sure what else happened that night; the last 12 hours passed chaotically in a fever dream haze. I recall my attending shoving my hand into the patient, instructing me to massage her atonic uterus post C-section, lest she hemorrhage.

“Chloe, are you safe to drive?” I was seated at a table somewhere, I couldn’t tell you where or how I got there, and I looked up incredulously at my resident’s exhausted, concerned face. If you’re worried about my driving, why were you okay with me in the operating room, hand inside a patient, just an hour ago?

I feel compelled to defend myself preemptively by clarifying that I’m not remotely averse to hard work or night float. I often start work in the psychiatric emergency department at 4 a.m. before running to my clinics for the day, and frequently, I’m not home until late in the evening between patient care, my responsibilities as one of the chief residents, and other work. Other nights, I’m at the hospital around midnight.

And I know why I have this defensive instinct: I know that someone, hiding at a distance, is just waiting to offer unpleasant assumptions about my perceived lack of dedication and competence, merely because I wrote this commentary.

“When I trained, we did 1 in 2 [24-hour call every other day] and worried about missing 50% of the action. You all are too soft.”

Or: “Doctors have always worked a lot. Maybe just get out of your head and care more about people.” (This came from a gentleman who is neither a medical doctor nor a scientist; he was just a man with an opinion.)

Consciously or not, the philosophy underlying these opinions appears to be driving the Accreditation Council for Graduate Medical Education’s (ACGME) proposal to roll back resident duty hour protections, including cutting the mandatory 8 hours off between shifts and reducing the 14-hour rest period after 24-hour in-house call, among other changes. This has the potential for adverse outcomes not only for resident well-being but also for patient safety.

Halsted and Humanity

We can trace the origins of residency culture back to a prominent surgeon at Johns Hopkins, William Halsted, MD, whose vision of residency meant a restrictive lifestyle: trainee doctors literally lived in the hospital (hence “residents”), were discouraged from marriage, and were expected to work unlimited hours. A severe cocaine addiction likely drove Halsted’s seemingly boundless reserves of energy through absurd hours, the basis for 24-hour call; indeed, patients floridly intoxicated on cocaine appear clinically manic, sometimes not needing sleep for days.

Anyone would be concerned if their doctor or colleague showed up to work like this, no? And you certainly wouldn’t take clinical practice advice from someone who is actively high. Yet, we’ve designed a system of medical education and derived an enduring culture of resiliency expectations based precisely on such advice.

We know instinctively that a chronically sleep-deprived and unhappy physician without social connection or the opportunity to be human cannot be a good physician. We’ve known since the 1970s that sleep deprivation and the austere inhumanity of Halsted’s training philosophy has detrimental effects on physician health and clinical performance — which can hurt patients directly. So, when residents on the ERAS interview trail wax lyrical about 24-hour call every 3 to 4 days because of the “learning opportunities,” I am dubious. And if you talk to them privately or anonymously, you’ll hear something different.

The 1984 death of college student Libby Zion at NewYork-Presbyterian from a fatal drug interaction drew national ire when it was noted that the intern who gave many orders in Zion’s care had been awake for over 18 hours. Zion’s father subsequently campaigned for medical education reform, having learned that residents routinely worked over 100 hours weekly, sometimes in 36-hour blocks: “I don’t know anyone who still works 24 straight hours in any other business. And these are people with lives in their hands.”

What’s the Motivation?

This is not to say that residency training should be easy, or even that 24-hour call should be unilaterally eliminated. Neurosurgery, for instance, may warrant physician presence for up to 15 hours for complex procedures, and other specialties may have service needs that warrant 24-hour shifts. Care during a night shift as the only psychiatrist on call is very different from care during the daytime and is a valuable experience. And ultimately, the purpose of residency is to train competent, autonomous, ethical physicians who can make hard decisions under pressure, handle unpredictability, and manage an emergency effectively.

But I don’t believe that rolling back duty hour protections and giving hospitals more opportunities to take advantage of residents’ relatively low status (and you know they will) under the guise of “education” is the means to that end.

My cynical mind says we’re cheap labor for hospitals and easy to abuse, given the one-sidedness of residency applications and the quiet reality that getting fired from residency dramatically complicates your career. In short, it’s hard for us to fight back without risking professional damage.

Considering the wealth of evidence that exhausted physicians can hurt themselves and patients, why else would the ACGME want to reduce the few protections we have?

The Same Fight

I landed in psychiatry because I love the field and it allows me to practice in a way that aligns most closely with my values as a physician: collaborative care through a biopsychosocial lens with a relational style to help me understand my patient comprehensively. To maintain the mental faculties to do that, I need time to be a person, not just a doctor. I don’t need a traditional 9-to-5 or all weekends and holidays off, but I do need adequate time to sleep, exercise, write, and be with my family.

Fortunately, I landed in a program that promotes all those things about me, beyond what I can do for the department’s patient volume. I’m a much more present, intellectually curious doctor as a result, and I actually work more hours by choice because my program gives me flexibility. I don’t think we sacrifice intellectual rigor and patient care by accounting for residents’ well-being with work hour protections; in fact, we might argue that the fight for one is the fight for the other.

The views expressed above are held only by the author and are not necessarily shared by the institutions with which she is affiliated.