Proper Medical Training Isn’t Brain Surgery
Dr. P. was dispensing insults and expletives, as usual. In the cardiac catheterization lab, a metal stent failed to expand correctly in the toddler’s heart and lodged in the femoral artery. A good interventional cardiologist could handle this complication, and for technical skill, Dr. P. was one of the best. With a renewed hail of invective, he instructed a young doctor (like me, a cardiology trainee) in the method of retrieving the stent through a thin catheter inserted into the artery.
The slow process was like coaxing a horseshoe through a garden hose. Frustrated and out of patience, Dr. P. took a scalpel and filleted open the toddler’s groin in an effort to ease the process. Like a fire hydrant, the artery spurted blood over the trainee’s face and surgical gown. It would take him three hours to stop the bleeding with direct pressure, and Dr. P. didn’t stick around. Before leaving, he looked at his trainee and said coldly: “Take a shower.”
How do doctors in training keep their sense of compassion and avoid turning into Dr. P.? For more than a decade, programs have focused on teaching sensitivity to doctors. But the efforts are largely misdirected.
Aspiring doctors always have known the value of compassion. It’s the context of later medical training as residents and interns that often makes them forget how to practice it.
As a former resident at my hospital once wrote: “In hell, I would dip my fingers in the water to wet the lips of Lazarus in torment, but in the hospital I am much too busy.” The point is, teaching the virtues of compassion in medical school won’t change future doctors. Instead, working conditions must allow them to display the compassion they already have.
National surveys show that medical trainees regularly work 80 hours a week, and 120-hour workweeks are common, according to the New England Journal of Medicine. (A week has only 168 hours.) Shifts can run 36 hours or more and can be scheduled repeatedly with just 12-hour breaks between them for weeks at a time. Over the last three decades, countless studies show increased depression, anxiety, confusion and anger in sleep- deprived residents.
The effects of overwork can be insidious; as a medical student, I worked with a surgical resident who, with a single sentence incorporating greeting, introduction and diagnosis, informed a young man that he had cancer of the small intestine. The poor man opened his mouth to ask a question, but the resident left before the patient got a word out.
Like this resident, all physicians in training bear a secret cross of disgrace. At some point, fatigue -- that birthplace of cynicism -- has made us ignore the emotional needs of a patient, and the shame haunts us.
In the early 1900s, William Halstead, the first chief of surgery at Johns Hopkins, established as the norm a 24-hour-a-day, seven-day-a-week period of “residency” for training surgeons and emphasized a restrictive lifestyle as the cornerstone of good training. Residency training has remained largely unchanged until recently -- fueled by the 1984 death of an 18-year-old college student named Libby Zion, which in part was blamed on the working conditions of residents at New York Hospital. A grand jury report two years later led the city health commissioner to issue work-hour restrictions.
The changes have been fought tooth and nail by residency program administrators. And an investigation in 1998 revealed that one-third of New York City medical residents and three-quarters of surgical residents were forced to exceed the work-hour restrictions.
As of July 1, national regulations have limited work hours of physicians in training to 80 hours a week, overnight call shifts to no more than once every three nights and workdays to a maximum of 30 consecutive hours.
These goals are modest, to be sure, but the doom of medical education is already being predicted. In a medical journal, one Brooklyn surgeon fumes: “Previously unheard of, sick days and personal days are now common. Furthermore, with the 80-hour limitation, [residents] feel that it is their right to do less work.” Residents these days, he continues, suffer from “laziness and lack of interest.”
Despite these opinions, I’m confident that the same profession that’s found a way of curing leukemia, making heart transplants work and conquering smallpox will solve the problem of training good doctors in fewer than 80 hours a week. From there, maybe we will turn our attention to reducing medical school debt, enhancing child-care options for residents with children and creating an academic system that rewards compassionate care with professional advancement.
Perhaps someday we’ll have more physicians like Dr. T. Several months ago, a toddler with congenital heart disease and worsening lung failure was admitted to the hospital where I’m training in pediatric cardiology. She was dying. The girl’s parents were very stressed, and their anger was often directed at the medical staff. Week after week, they banished several earnest young doctors from the room, yelled at nurses and liberally cursed at various staff members -- many of whom no doubt dreaded seeing them and avoided unnecessarily entering the child’s room.
One weekend, when the parents returned briefly to their home in Alabama, their daughter took a turn for the worse.
Dr. T., the on-call physician who also hadn’t been spared the parents’ verbal assaults, called to give the bad news. The parents needed to fly back right away because the situation was critical. They exclaimed, “We can’t afford a last-minute flight!” They were desperate and afraid. Dr. T. spoke to them a little longer and told them not to worry.
Only later did I learn what happened.
Dr. T. redeemed his own frequent-flier miles to fly them back, so they could be with their daughter in her final hours.
Darshak Sanghavi is a clinical fellow at Harvard Medical School and author of “A Map of the Child: A Pediatrician’s Tour of the Body” (Henry Holt & Co., 2003).
