[ Medical School Resources | Appendices | ]
From Residents: The Perils and Promise of Educating Young Doctors, published 1996:
Late last year, the Federal Aviation Administration, citing extensive data blaming fatigue on airline crashes, announced it will seek to cut the maximum hours a commercial airline pilot can be on duty from sixteen to fourteen hours, and to increase rest periods between shifts.... This follows the enactment of the FAA rule requiring that pilots take naps in the cockpit on trans-Pacific flights - a policy approved despite considerable opposition by airlines - because studies have overwhelmingly proven that naps reduce instances of pilots falling asleep at the controls.
[In the Persian Gulf War] The U.S. Army likewise ordered combat officers to get at least eight hours of sleep in every twenty-four after extensive research demonstrated 'sleep deprivation causes leaders to... make mistakes and decisions which cause the death of... their units.'[321]
Libby Zion. Found dead in restraints in a New York City hospital at age 18 in March, 1984. It's bad form to kill daughters of New York Times columnists, especially when they are also former federal prosecutors. After amassing 1400 pages of testimony, a grand jury found that the long working hours of residents had contributed to Libby Zion's death. The grand jury was also convinced that the conditions leading to her death prevailed at many teaching hospitals. Eleven years later, a jury ruled the doctors must pay $375,000 to the Zion family for pain and suffering.[322]
As described in the New Physician, the grand jury report made people aware of the "big secret." The training of a resident physician has been called, "one of the last great sweatshops in America."[323] Some feel that the long hours of medical students are necessary to guarantee the most learning in the least time. The alternative view is that sleep loss plays, "a critical part in the dehumanizing or even brainwashing process of medical initiation."[324]
Rachel Naomi Remen: "There is something odd about a person who has had five hours of sleep in the last two days telling another person to go home to bed."[325] JAMA describes "very sensitive" interns catching themselves beginning to wish that the patients would just die, so that he could get out of the fatigue-tension cycle.[326] An example from To Do No Harm: "At three o'clock in the morning as I stood over [a comatose patient's] bedside starting his IV he was the enemy, part of the plot to deprive me of sleep. If he died, I could sleep for another hour. If he lived, I would be up all night."[327] A resident writes her advice in the Journal of the American Women's Medical Association: "Push for hours reform instead of letting yourself turn into a monster."[328]
Because of Libby Zion, activists in New York did just that. Public Health Law 405.4, Paragraph 2.b.[329] New York became the only state in the U.S. to regulate resident hours. In contrast, all European Union countries are presently required to restrict workloads in the hospital to seventy-two hours a week. Britain is gradually winnowing their seventy-two hour work-week down to fifty-six hours. Ontario has a limit of sixty hours.[330]
Of course the law is worthless if it's not enforced. My mom sent me a clipping of the March 3, 1998, Wall Street Journal's "Raid of Hospitals Probes Overworked Doctors":
NEW YORK - With surprise raids on a slew of top academic medical centers here, state authorities launched a sweeping probe to stop hospitals from overworking young doctors. The inspections began last Thursday morning, when squads of state inspectors descended unannounced onto some of the nation's most prestigious hospitals.... The state officials demanded documents, charts and access to medical and surgical residents....
The results were reported later in Modern Healthcare. Almost a decade after New York State passed the hour-limiting laws, the investigation of 12 hospitals by state medical officials found that all 12 consistently break the laws. The surgery programs were the worst offenders. Based on extensive surveys of the residents in those hospitals, the officials found that 77 percent of surgical residents in New York City worked in excess of 95 hours a week. "By and large," Modern Healthcare reports, "many of the surgical programs are lying (by printing) fake on-call schedules."[331]
Regionally, New York City had the worst compliance. According to the New York Times, the investigation found that nearly all the residents at the seven hospitals investigated in New York City worked longer hours than the laws allow. The State Health Commissioner Barbara DeBuono said the results showed that the hospitals made almost no effort to curtail residents' hours.[332] She described herself to the Daily News as, "very, very disturbed" by the findings.[333] Residents, on the other hand, reportedly expressed little surprise at the hospital's abysmal compliance record.
"The profit that doctors and hospitals derived from house staff was one of the driving forces of the postwar medical system." - Pulitzer-prize winning The Social Transformation of American Medicine[334]
Since the hour-limiting rules were enacted over ten years ago, New York hospitals have collected hundreds of millions of dollars from the state to make up for lighter resident schedules. When the regulations were originally drafted, the hospitals demanded that they would need the money to pay others to take the residents' place. Of course what the hospitals did was to continue to overwork residents while, in the words of Bertrand Bell - the drafter of the original regulations - they, "acted like a Woody Allen movie - they took the money and ran."
Quoting from JAMA, "'The patient always comes first'... is a misleading shibboleth that confuses true instances that require devotion to the patient... with tedious tasks shunted to the house staff because they are in no one else's job description and no one does them cheaper than do residents."[335] "Happy slaves" - a hospital department chair sharing his conception of ideal residents.[336]
"We're cheap labor, let's face it," one resident explains. "I mean, we're not even making minimum wage, so they've got a good thing going."[337] Also, interns' hours are infinitely flexible, especially if one ignores the regulations. "It's called slave labor," said Mark Levy, associate director of the Committee for Interns and Residents, a New York-based union. At $30,000 to $40,000 a year and 100 hours of work or more each week, "They're the cheapest workers in the hospital." So, hospitals cut costs by reducing nursing and support staff and the residents bear the brunt of it.[338] One doctor asks, "Is it wrong to use physicians-in-training to serve the economic interests of hospitals and medical staff, when it might not serve the interests of either the patients or residents?"[339]
An article in Mother Jones describes why medical students are taught how to guard the subsidy secret:
Medical schools benefit from billions in government grants.... If the public knew to what extent it subsidizes doctors - and how little it gets in return - the response might be radical. In exchange for a medical education, doctors could be forced to participate in public health programs.... The terror this prospect inspires is one reason doctors tend to be so politically conservative. The best defense against paying back some of what they owe is to keep the free enterprise rhetoric flying high. As long as the public doesn't know they're on the dole, physicians can assume the lifestyle that they have come to expect.[340]
In opposition to the hour limiting regulations, New York residency program directors were reported as saying, "residents would not receive the tough training necessary to prepare for the rigors of medical practice." Dr. William Speck, the president and CEO of the New York and Presbyterian Hospital, decried the state investigations as, "an unfortunate event." Dr. Speck slammed the regulations as, "ridiculous, very arbitrary, and very capricious." He added: "I think residents have to get the appropriate amount of sleep, but more important, they have to get the proper amount of instruction."
Why is New York still the only one state with hour-limiting regulations? It's the fault of surgeons. According to Bertrand Bell, it was the American College of Surgeons that bitterly fought enactment of these rules by their own and all the other specialty boards. The American College of Surgeons evidently blocked the American Council of Graduate Medical Education, the American Association of Medical Colleges and many other medical organizations from officially endorsing any standard limits on the working conditions of residents.[341]
"The medical community is saying that somehow the laws of physiology apply to everyone else, but not to them," says Merrill Mitler, director of sleep research at the Scripps Institute.[342] "Healthcare workers are some of the most egregious violators of common sense as it applies to our own lives" - Clinical Director of the Florida Center for Sleep Medicine.[343]
Dr. Ward Griffen, head of the American Board of Surgery, put it bluntly:
I think it's the biggest bunch of hogwash there is. All this jazz about sleep deprivation is way overplayed.... I think the people who are pushing this are the ones who can't get by on a little sleep.[344]
[321] Duncan, DE. Residents: The Perils and Promise of Educating Young Doctors New York, NY: Scribner, 1996:105.
[322] "Zion v. NY Hospital" February, 1995.
[323] Duncan, DE. Residents New York, NY: Scribner, 1996:129.
[324] Chamberlain, A. "Night Life." New Physician 1981(May):28-30.
[325] Remen, RN. "Humanistic Medicine: The Myth of Service." New Physician:41.
[326] Grouse, LD. "Dirtball." Journal of the American Medical Association 247(1982):3059-3060.
[327] Reilly, P. To Do No Harm: A Journey through Medical School Dover: Auburn House, 1987:226.
[328] Schneider, K. "Abuse in Medical Education." Journal of the American Women's Medical Association 45(1990):216-217, 234.
[329] Laine, C, et al. Journal of the American Medical Association 269(1993):374-378.
[330] Duncan, DE. Residents New York, NY: Scribner, 1996:230.
[331] Modern Healthcare 19 September 1990.
[332] Kennedy, R. "Residents' Hours Terms Excessive in Hospital Study." New York Times late ed. 19 May 1998:1A..
[333] "State Asleep on Doc Law." Daily News 20 May 1998:34.
[334] Starr, P. The Social Transformation of American Medicine New York: Basic Books, May 1984.