Physician, Heal Thyself--Try to Get Some Sleep

When the patient walked into the room and explained his problem, Dr. Marie Pitaro knew she should probably spend more time with him to try to figure out exactly what ailed him.

But, concluding that the patient’s complaints about anxiety could wait, Pitaro instead asked him to make an appointment to come back another time.

Pitaro, 36, had been working for more than 30 hours at Boston City Hospital with virtually no sleep and just wanted to go home and go to bed.

“By that time my sympathy level was pretty low,” said Pitaro, who is in the third and last year of her post-medical school training as an internist. “I was just so exhausted and frazzled.”

Dr. Allan Hamilton, 37, in the sixth year of a seven-year neurosurgery training program at Massachusetts General Hospital, tells stories about residents literally falling asleep in the operating room.

“I’ve seen residents fall asleep holding a retractor. I’ve seen a resident fall asleep looking through a microscope during microsurgery,” Hamilton said. “There have been occasions when I’ve felt I was less sharp then I would like to have been.”

Such incidents illustrate what has become the center of a debate among medical educators that could lead to dramatic changes in a time-honored rite of passage that doctors have gone through to train for their profession.

New York is scheduled next spring to become the first state to implement regulations limiting the number of hours that can be worked by doctors in training--known as house officers, residents, interns and fellows.

Programs Scrutinized

The move has prompted state officials and medical educators nationwide to scrutinize their training programs. Legislation similar to that approved in New York is pending in several states, including Massachusetts.

“It’s something that should have been done a long time ago,” said Dr. David Daigneault, president of the National Federation of House-staff Organizations, which represents some of the estimated 60,000 residents at 1,300 teaching hospitals nationwide.

“Medicine has changed over the past 20 years in leaps and bounds. Future shock has taken hold in medicine as much as with any scientific field. But residency hasn’t changed one bit,” Daigneault said.

At issue is the grueling hours most residency programs demand. Young doctors routinely work between 80 and 100 hours a week and often go for days with little or no sleep.

Because these are the people providing most of the care to patients in hospitals, many question whether the approach compromises the quality of care. They also question whether this is really the best way to train doctors.

Others argue that long hours are necessary to provide young doctors with the experience they require to become good doctors, and to get them used to what life will be like as physicians.

The training is taxing, but patient care is always the top priority, with residents always being backed up by more experienced doctors, they argue. Strict regulations would also most likely require the hiring of more staff, which would be very costly in these days of spiraling costs, they say.

But even Pitaro and Hamilton disagree. Pitaro supports state legislation to limit the number of hours to force hospitals to hire personnel to take some of the less specialized work off the backs of residents. Hamilton believes patient care would be endangered and fears that changes would diminish or extend his training.

The current system for training doctors dates back to the days when hospitals were places where most patients were convalescing and required relatively little attention.

Advances in medicine have filled hospital wards with very sick patients who require intense care. So the same number of patients require much more work to care for.

“In the old days there was old Mr. Jones dying quietly in the back room and there wasn’t much you could do,” said Dr. Arnold Relman, editor of the New England Journal of Medicine. “But today the good old days don’t apply anymore. In the good old days you could get plenty of sleep.”

Working All Night

When a resident is on call at night--which can be every few days--it is routine for that person to be up all night, admitting new patients and making critical decisions about patients who have been in the hospital.

Chief among the arguments that the system needs changing is the image of a relatively inexperienced doctor making important decisions in the middle of the night or the day after a sleepless night when his or her mind is foggy.

There are regulations requiring proper sleep for truck drivers and airline pilots, proponents of change argue. So shouldn’t the same types of common-sense rules apply to doctors?

But not everyone agrees. Many argue that residents can adequately care for patients with little or no sleep. When the pressure is on, the doctor is revved up by adrenaline and is careful to check and double-check his or her decisions, they argue.

“You have to use some common sense in this situation,” said Dr. Richard Cohen, a psychiatrist at the University of Pittsburgh School of Medicine who recently wrote “House Officer,” a book about residents’ experiences.

“What these people say is, ‘Sure it’s no fun. But when you’re sleep-deprived on the next day you know it. So you watch yourself. You don’t take chances. You don’t run risks,’ ” Cohen said.

15-Hour Days

Hamilton routinely works 15-hour days that consist largely of eight- to 10-hour stints in the operating room without a break--even to go to the bathroom. These days make up 80- to 120-hour weeks during which he is on call every third night. On those nights he often gets little or no sleep.

But he agrees that when it comes time to perform, he and his colleagues are certain they can.

“When you’re operating there’s a lot of adrenaline flowing,” Hamilton said. “It’s sort of like rock climbing. Nobody’s going to fall asleep when they’re climbing a rock face.”

Although Hamilton admitted there can be a macho attitude in residency programs--especially surgical residencies--most residents know enough to admit when they are too tired to perform safely.

“I’m not going to lie to you. There’s a real macho mentality about surgery. But I’ve never had someone tell me I couldn’t leave an operating room because I’m too tired,” he said.

Can Still Function

A study of 26 residents published last summer in the Journal of the American Medical Assn. looked at just this question. It concluded that the scant sleep residents get does not impair their ability to function well.

Sleep experts, however, criticized the findings, questioning the methods the researchers used. And many medical experts scoff at the notion that lack of sleep has no impact.

“Everybody knows there comes a point when you’ve worked too long and been deprived of sleep so much that it affects your functioning,” Relman said.

Pitaro and Hamilton agreed that in most cases chronic fatigue does not cause life-threatening mistakes. More likely it slows routine tasks or diminishes a resident’s ability to be as patient and sympathetic as he or she should be.

Some argue that resistance to changing the system stems from tradition akin to fraternity initiation or the boot camp experience of the military. Some older doctors who are in decision-making positions think new doctors should go through what they went through.

“Part of it is there’s a rite of passage in medicine. The internship is considered one of these sacred rites of passage you have to go through to be considered a man of medicine,” said Dr. Joseph Flaherty, a professor of psychiatry at the University of Illinois College of Medicine in Chicago, who is critical of such arguments.

Time for Observation

But some educators argue that doctors in training need to see the various stages of disease first-hand. And a sick patient’s progress does not fit nicely into an eight-hour day.

“It’s only by giving that care, seeing it’s response, measuring it . . . that one can learn to be a good doctor,” said Dr. Robert McAfee, a Portland, Me., surgeon and a member of the AMA’s board of trustees.

But others counter that residents do not need to be sleep-deprived to gain experience with diseases in all their manifestations. They can be scheduled to work various hours, but in such a way that they get the rest they need.

“We want to set up schedules that will give you a reasonable chance that the people involved will be physically and emotionally capable of taking care of a patient,” said Dr. Bertrand Bell, who chaired a commission that recommended the changes in New York. “If you think that 80 hours a week is not a lot of hours, you’re crazy.”

Hands-On Treatment

Another argument for the existing system is that the best way to learn is through experience, to treat as many patients as you can and, say, in surgery, perform as many operations as possible.

Hamilton said he was concerned that if the number of hours a resident could work was limited, already long residency programs like his would have to be made even longer.

But again, proponents of change counter that while such experience is invaluable, there has to be a limit and a balance that does not compromise patient care. And how much can you actually learn when you’re tired?

“When you are really tired all you want to do is get out of the hospital, go home and get into your bed. It’s an overwhelming need to go to sleep. You kind of go on automatic pilot. Your interest in learning about the disease process is just not there after 36 hours,” Pitaro said.

But some also argue that if someone can not handle the long, demanding hours of residency, they may not be cut out to be a doctor.

“Let me tell you something. If you can’t handle 80 hours a week you’re in trouble. And if you can’t handle sleep deprivation you’re in trouble,” Cohen said.

Testing Opportunity

Hamilton said: “It gives you a chance to really test yourself, to really see what you can deliver under the most trying circumstances. It’s a trial by fire, a trial by combat. When it’s over, I think you emerge as a better surgeon.”

McAfee also argues that there are other benefits.

“I think there are certain aspects of the residency training program that establish lifelong habits--being able to say that patients’ care is more than important than their own individual well-being,” said McAfee.

But Pitaro and others say that if hospitals hired more support staff, residents would be freed from such work as taking blood and transporting patients, and they would have more time to rest and learn.

But even most supporters of the current system admit that some changes could be made; some programs are worse than others and the demands vary from specialty to specialty.

The American Medical Assn. is in the middle of a comprehensive study of residency training programs, examining a wide variety of factors such as differences by region, hospitals and specialty, McAfee said.

Recommendations Sought

The study is expected to be completed by June, after which recommendations will be issued for any changes to the various committees that oversee accrediting residency programs for each specialty nationwide.

“We’ve long had concerns for residents working too hard. But we are not making recommendations to anyone until these studies are done,” McAfee said.

Many also expressed concern about paying for any changes in the system. Limiting hours will in all likelihood require the hiring of more doctors, nurses and technicians. The changes being made in New York may cost as much as $300 million a year in that state alone.

“Hospitals are under a serious enough problem as it is. Their backs are to the wall. It simply makes no sense to institute any kind of reform in house officers’ working hours that’s going to significantly increase costs without considering the impact on the hospital. You can’t get blood from a stone,” Relman said.

Relman also expressed concern about state governments stepping in and ordering strict limits on hours, saying that medicine varies so much from specialty to specialty that such decisions are best left to educators.

“It seems to me dubious that the problem is best solved by interference by state government by legislative fiat,” Relman said.

“The role of government ought to be simply to require that hospitals indicate that they are doing something about it and report what they do,” he said. “You can’t fit them all into the same cookie cutter.”

Skepticism Voiced

But Dr. Jonathan House, executive director of the committee of interns and residents in New York, said he was skeptical that the medical profession would ever reform itself.

“Reform is not going to come from the profession. Reform is not going to come from the same people who have been denying there is a problem,” House said. “If war is too important to be left to generals, health is too important to be left to doctors.”

Cohn argues that his research found residents were more concerned with improving the amount and quality of supervision they received than with reducing their hours.

“Over and over and over again that’s what I heard from these people,” Cohen said. “Yes, who wants to work 100 hours a week? But if we had teachers who were interested in us, I would give 150%.”

Dr. Thomas Delbanco, who heads the general medicine training program at Beth Israel Hospital in Boston, said his hospital is experimenting with an approach aimed at reducing residents’ workloads.

Separating Patients

The approach involves moving patients who are awaiting transfer, perhaps to a nursing home, to a ward where residents do not treat them. These patients are of limited educational value, he said.

“It may end up that if we can free up enough of the house officers’ time we could have them working fewer hours,” Delbanco said.

“It is a very complicated education issue. There is no question that it is unreasonable to have young people who are exhausted, who can’t think straight, attending to the needs of patients,” he said.

“On the other hand, learning to be a doctor has to be an extraordinarily intense experience. From the point of view of learning to be a doctor, the more time one spends with patients the better,” Delbanco said. “The trick is to find the proper balance.”