"The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head."It's barely dawn on a nippy fall morning, and Nita Ahuja has already put in what many people would consider almost three full days' work. She is a Hopkins chief surgical resident who is on a rotation at Sinai Hospital in Baltimore. A petite woman who exudes confidence, Ahuja (pictured above) has been on call for 24 hours. During that time she's managed to fit in about four hours' sleep--"a good amount for a night on call," she declares.
Since her beeper woke her around 3 a.m., she's attended to a gunshot victim, resuscitated an older woman with a rapid heart beat, ordered tests for a patient with bleeding fibroids, and dictated some notes. At 6:30 a.m., she meets up with four other interns and residents--her team--and begins morning rounds, a procession that will include stops at 28 bedsides.
Ahuja's constant presence at Sinai does not go unnoticed by some of the patients. She and her colleagues enter the room of an elderly woman, just as the sun angles its way up the brick wall outside the room's one window. The patient smiles up at Ahuja. "Don't you ever go home?" she asks.
"I don't, but let me tell you, you get to go home today!" Ahuja replies.
6:30 a.m., 5 p.m., midnight... Hopkins residents like Ahuja witness every hour from the timeless interiors of Sinai Hospital, Johns Hopkins Hospital, Bayview Medical Center, and other Baltimore hospitals that are their training grounds. These hospitals never close, and residents help assure that their doors remain open 24 hours a day, 365 days per year. Hopkins surgery residents, whose specialty is the most time-demanding, averaged 93 hours on duty per week, according to a survey conducted in 1999. Some worked as many as 114 hours weekly.
Long, grueling work hours are part of a century-old tradition in resident training, but in recent years they have also become the focus of a rancorous debate.
Defenders of the current system contend that residents must log
the hours they do in order to experience a sufficient variety and
volume of clinical cases. While medical students read textbooks,
residents must learn by doing. In the real world of the hospital,
patients do not get sick on schedule, and it is unrealistic--not
to mention financially impossible, given the current system--to
think that residents could work more conventional hours.
But such reasoning has come under fire from critics who argue that sleep-deprived residents may endanger their patients' and even their own health and safety.
At Hopkins the issue gained national prominence last fall, on the six-part ABC News documentary Hopkins 24/7. In the final episode, third-year surgery resident Risa Moriarity (MD '97), shown struggling through a 60-hour shift, announced in front of millions of television viewers that she was resigning, largely because of the long hours her five-year residency required.
"At least in my residency program, residents fell asleep at the operating table fairly routinely," Moriarity later told online participants, in a "chat" arranged by ABC. "And in most cases the resident is not asked to leave [nor is] relieved by someone else, they are left there to continue nodding off....At a certain point, exhaustion impairs your ability to function as a surgeon. And I would also argue that those work hours affect the safety of residents themselves, because practically every surgical resident I know has fallen asleep at the wheel on the way home from work, and a number have been in accidents because of it." (Studies like one done recently at Wayne State University back up Moriarity's charge; a survey of emergency medicine residents nationwide found that accidents attributable to sleep deprivation increased by a factor of seven following the start of the residency.)
There is no reason that residents cannot learn all they need to know in an 80-hour work week, concluded Moriarity, who has since joined the Internet start-up HealthCite.com as executive content editor.
Moriarity's remarks caused consternation among many of her colleagues and some medical faculty at Hopkins, who believed that ABC had oversimplified the issue of residents' working conditions. (Moriarity declined to be interviewed for this story.)
All residents complain about work hours, says Susan Mani, a third-year resident in medicine, and president of the House Staff Council, the elected body that represents Hopkins residents. "The only way to vent is to talk about it," says Mani. "Most people already know that the hours are going to be long. But you never realize how long they're going to be until you're in the job. It is probably one of the most difficult aspects of the job."
Mani's sentiments are echoed by Ahuja, whose life is further complicated by the fact that she gave birth to her first child, a son named Soren, last year. "I've wanted to be a doctor my whole life, since I was a kid," says the 34-year-old. And lack of sleep is something she accepts as just one of the challenges in her path to becoming a gastrointestinal surgeon. Ahuja is completing the seventh of the nine-year slog it will take her to attain that goal. During the months of her pregnancy, she never missed a day's work, and she worked right up until the hour she went into labor (after which she took a six-week maternity leave).
Ahuja says she would not be able to juggle the demands of new motherhood were it not for the help of her mother, Deshi Ahuja. Her mother quit her job last year and moved in with Ahuja and her husband, Rajesh Saggi, to care for Soren. Given the fact that Ahuja is on call every third night, her mother's presence is invaluable, she says.
Despite the sacrifices, Ahuja believes the rewards of medicine are well worth the punishing schedule she must follow for the next several years.
Of course, being a resident has never been a 9 to 5 job. In fact, residents in the past may have even worked more hours than they do today.
The residency system in the United States began at Hopkins in 1889 under William Osler, first director of the Department of Medicine and first physician-in-chief of Johns Hopkins Hospital. Following the German model of postgraduate medical training, Osler established a plan in which young physicians trained under an experienced mentor. Residents learned by doing clinical work, taking on increasing responsibilities as they gained more experience, and graduated from intern to junior resident to senior resident to chief. Over the years, other hospitals adopted the Hopkins model, and it became the norm for training doctors.
Osler, who once wrote an essay on the medical profession titled "The Master-word is Work," expected residents to be fully committed to the role of doctoring. Residents lived at the hospital and were not allowed to marry--rules that continued until the end of World War II. Most residents were so caught up in the intellectually charged atmosphere of the time that they put up with the sacrifices.
"It was an even more grueling job, even more absorbing in the past than now," says 80-year-old Victor McKusick, University Professor of Medical Genetics. After an internship and junior residency at Johns Hopkins Hospital in the late 1940s, McKusick in 1951 became chief resident on the Osler Medical Service.
"There was very little scheduled off-time," says McKusick.
Interns were on call every other night. Residents worked all
through the week and all day Saturday. On Sunday morning, they
performed rounds, and then, if they could arrange to leave their
patients in the care of a fellow intern or resident, took the
rest of the day off.
"We didn't feel put upon or enslaved," adds McKusick. "This was just the way it was."
"It was a pyramidal system," says cardiac surgeon Levi Watkins, associate dean at the School of Medicine. He began his residency at Hopkins in 1971, as one of an entering class of 22 physicians that was whittled down to two residents by the time he completed the program in 1978.
"We were on call every other night, and in cardiac, we were on call five nights of the week," says Watkins. "It was a culture of survival. Do what you've got to do."
So what's different today?
"There's more work to do now and less time to do it," says David Leach, executive director of the Accreditation Council for Graduate Medical Education (ACGME), which oversees 7,700 residency programs at 839 hospitals and medical schools in the United States.
When McKusick was a resident, patients stayed in the hospital for two weeks or more. Residents had full responsibility for their patients, and even performed many of the lab tests. "A tremendous bond was established between the house officer and the patient," McKusick says.
Today, hospital stays are shorter, largely because managed care companies have reduced length of stay. Thus, hospitals can admit and discharge an increasing number of patients. The result is that within any span of time, residents see more patients than they used to.
Says Leach, "A shorter length of stay is frustrating for residents. They don't really get to know their patients even though they know their disease." The job is more clinical, less personal, and probably more stressful.
Further, today's patients are probably much sicker than they were during McKusick's residency. "The level of acuity of illness of patients in the hospital has gone up tremendously," says surgeon Keith Lillemoe, who did his residency at Hopkins from 1978 to 1985 and now directs the surgical residency program. "Today, only the really sick patients or those who have big operations stay in the hospital. Doctors really do work very hard to take care of them."
The level of care is also more complicated, says Hopkins vice chair for medicine Charles Wiener, director of the Osler medical training program. "Patients have a lot of social needs," he says. He has seen a sharp rise in the need for social services: patients with drug or alcohol addiction, who have experienced physical abuse, who lack health insurance.
Such growth has outpaced any increases in social workers, case managers, and other resources available in or out of the hospital, says Wiener. As a result, medical interns and residents now spend a fair amount of their time handling such problems, for example tracking down a rehabilitation program for a drug user who has no medical insurance.
Greg Galdino, a fifth-year plastic surgery resident, believes that hospitals should try to limit work hours to 80 per week for all residents. But the number of work hours is not the underlying problem, says Galdino. It's the system itself. "I think it's extremely antiquated," he says.
Residents, especially junior residents, says Galdino, perform many tasks that do not require a medical degree: filling out insurance forms, completing admission and discharge papers, searching for X-rays, transporting patients. As a junior resident, he probably spent 75 percent of his time on such duties, he says. "A lot of your first years, you're an information-getter, a gofer," he says. "I don't think the hours are utilized efficiently."
Moreover, Galdino was disappointed by how little he got to do in the operating room. "In surgery, you're nothing but a retractor. I felt it was a very poor way to learn." He was so disheartened, in fact, that at the end of his second year in residency, he considered dropping out. He decided to persevere, he says, in part because the department was making efforts to be more "resident friendly."
Galdino decided to stay for another reason. He became involved in research aimed at developing surgical simulators, computerized systems that enable doctors to practice removing a gallbladder or appendix or performing another procedure before even touching a patient. Galdino hopes the systems will improve the efficiency of training surgeons.
Nationally, the residency system has not been without reforms. Perhaps the most visible change has been instituted in the state of New York. There, a law governing the work hours and supervision of residents arose as a result of outrage caused by the 1984 death of 18-year-old Libby Zion. The teenager was admitted to New York Hospital at midnight with fever and minor flu symptoms. She died seven hours later.
The immediate cause of Libby Zion's death is still debated. One factor may have been the potentially lethal combination of the drugs Nardil, which Zion had been taking, and Demerol, which she was given in the hospital. But her father, Sidney Zion, a journalist and former federal prosecutor, blamed severe flaws in the residency training system as the underlying cause. He launched a passionate campaign, arguing that lack of sleep on the part of the intern and resident, and inadequate supervision by the attending physician, contributed to this medical blunder.
A grand jury in New York heard the case but did not indict the doctors involved. Instead, it implicated the residency system as a whole.
The case prompted the New York state health commissioner, David Axelrod, to form a committee to investigate issues in emergency care, including the training of physicians. It was headed by Bertrand Bell, a Distinguished University Professor and professor of medicine at Albert Einstein College of Medicine. After 19 months of testimony, the Bell Commission issued a report recommending specific limits on residents' work hours and stricter rules regarding their supervision.
In 1989, New York enacted changes in its health code that roughly followed the Bell Commission's recommendations. According to Code 405, residents may work no more than an average of 80 hours per week. They must have off at least one 24-hour period per week and at least eight hours between shifts. The law also requires that an experienced supervising physician be in the hospital at all times or, in certain cases, no more than 30 minutes away from the hospital.
So far, New York is the only state that has adopted a law governing resident work hours. But the Libby Zion case has had reverberations around the nation.
The ACGME requires that hospitals or universities sponsoring a residency program set policies that take into account both the educational needs of the residents and the need for patient care. Each of the 27 residency review committees under the ACGME now requires that residents be on-call in-house no more than one night out of three, and have off at least one day per week. In addition, five of the specialties (surgery is not one) now limit resident work schedules to an average of 80 hours per week, and a sixth sets the limit at 72 hours.
In recent years, the ACGME has begun to crack down on enforcement of these rules. In 1999, it reviewed 86 hospitals and issued citations to one- fifth of them for violations. The worst offenders were the surgical specialties. Sufficient citations can lead ACGME to withdraw accreditation, which means a program would lose its Medicare funding. "So it's a fairly heavy lever," says Leach. New York, as well, has fined several hospitals for violating its work limits.
Is patient safety truly at stake? Those who support measures like Code 405 clearly believe it is. If the Federal Aviation Administration restricts the number of hours a pilot can fly, then why shouldn't doctors be subject to similar limits?
Hopkins physicians like surgeon Keith Lillemoe, who directs the surgery training program, say that "theoretically" the potential for disaster is there, but he adds, "I think the level of supervision is so high, we don't allow it to be. If a tired resident can't make a decision, there's someone there to make a decision for him or her. We have one or two attendings in the hospital at all times."
Surgeons in general--not just residents--put in long hours and do not always get enough sleep, Lillemoe says. Occasionally, he says, a resident who is observing or playing a minor role in an operation will "nod or jump. But I've never in 25 years seen someone fall to the ground or contaminate the surgical field or let a retractor slip."
Many surgeons cite another phenomenon: "When an emergency arises, it's amazing how sharp your skills become," says Ahuja. "When I'm operating, I'm totally concentrated and focused on it. That surgeon mode comes on. When a trauma comes in, you're the director. You're not thinking, 'I'm tired.' Of course, after that, you crash."
Some studies on sleep deprivation support this claim. They indicate that acute sleep deprivation does not diminish a resident's dexterity, eye-hand coordination, or reaction time. However, a night without sleep does seem to impair a resident's performance on tasks requiring vigilance. Thus, one interpretation is that lack of sleep might be a bigger risk for an anesthesiologist whose job requires a high degree of vigilance than it would for a specialist who performs a lot of manual tasks.
And while many of these studies have examined the effects of acute sleep deprivation--for example, how well a physician performs in inserting a breathing tube following a night on call- -there has been little research on the effects of chronic sleep deprivation, such as may result from working 80 hours per week and being on call every third night for months on end.
At Hopkins, there is no hospital- or university-wide policy
governing residents' work hours, says associate dean Watkins, who
chairs the Joint Committee on House Staff and Postdoctoral
Programs. Hopkins has 71 specialty and subspecialty training
programs. Each must adhere to ACGME standards, and is subject to
academic review every two years before the joint committee. All
aspects of the programs--including work hours--are closely
scrutinized during the review process, says Watkins.
However, he adds, "Nobody says, 'They must work a certain number of hours.'" Many supervising physicians follow a common-sense approach. "When I know my resident worked all night, I say, 'Chill out.' It's one of my rules for promoting a culture of civility."
That said, Hopkins has paid closer attention in recent years to overall working conditions. In large part, these efforts have been driven by demands of residents themselves. "We have to compete with other great hospitals," says Watkins.
In 1992, Hopkins approved a one-week paternity leave policy for residents, having already adopted an eight-week maternity leave policy the year before. And with House Staff Council prompting, Hopkins agreed to pay for food vouchers that residents can use when they are on call.
Other recent changes strike more closely at the heart of the work hours issue. In recent years, most clinical units at Hopkins have reduced the number of nights their residents are required to be on call. When Ahuja began her surgical residency in the early '90s, she worked "Q2"--doctors' shorthand for spending every other night in the hospital. She and all other surgery residents now generally work "Q3," being on call one night out of three. Ahuja says she never would have been able to manage having an infant if the program had not instituted the change.
In surgery, Lillemoe requested and received permission to hire 10 nurse practitioners and physician assistants. The new staff will help lighten the workload for residents by performing tasks--such as drawing blood--that do not require an M.D. Lillemoe is hoping that they will help cut down on his residents' work hours. Surgery, which now trains approximately 70 residents, is also adding an additional chief resident slot.
Other programs have implemented similar changes. The Department of Medicine--in addition to increasing its nurse practitioner/physician assistant staff by 10--has added 10 members to its house staff, bringing the current total to 106. "The stated goal was to increase the amount of elective and research time for residents," says director of training Wiener.
There are financial limitations to hiring even more house staff, says Watkins. Johns Hopkins currently employs approximately 660 house staff; these doctors earn between $34,000 and $55,000 each.
Medicare pays for the cost of training 385 of Hopkins's roughly 660 house staff (interns, residents, and fellows). The remaining cost--at least $20 million--is shared by Johns Hopkins Hospital and the School of Medicine. If Hopkins adds additional house staff, it must pay for the entire additional increase in training costs.
Lillemoe believes the recent increase in surgery staff is money well spent. He suggested the increase after seeing the results of his 1999 survey of resident work hours. Seeing that surgical residents on average worked 93 hours per week did not disturb him so much as the fact that some residents exceeded those hours, logging up to 114 hours in a seven-day period. Do the math and you'll find that comes out to 16-hour days, seven days a week. Throw in one day off, and the equation jumps to 19-hour workdays.
But there is another factor to consider, says Lillemoe. Residents
who work these extremely long hours are not coerced by their
superiors--in fact, they are discouraged from doing so. Often,
residents volunteer to work a long shift so that they may have a
full weekend off.
Residents in general, and perhaps surgery residents most of all, are also extremely self-motivated, says Lillemoe. "They are like Olympic swimmers," he says. "These individuals are the most dedicated in the world. They've succeeded by being that dedicated."
"With the high quality and dedication of the residents we have," he says, part of the hospital's reform efforts need to be aimed at the residents themselves--at changing their attitudes so that they believe "it is acceptable to sign out."
Some seasoned physicians say that certain rigors of medical training, including the grueling pace of the current residency system, should not be regulated to the extent that New York is doing. One of them is surgeon John Ricotta (MD '73), who did his residency at Hopkins in the 1970s and is now director of surgery at the State University of New York at Stony Brook. His son, John, is a surgical intern at Hopkins.
The elder Ricotta says New York's Code 405 is rigid and doctrinaire--"repugnant." It disrupts the continuity of care that patients deserve, he says.
"The operation is a very strong bond between physician and patient. It's probably stronger than any other bond in medicine. Being in the operating room and inside their body ties you to a person in a way that others cannot understand," Ricotta says. "It is an important part of the surgeon/patient relationship.
"If you operate on a patient, it is very difficult to pass that patient's care off to someone else. Eighty-five to 90 percent of the time, everything is fine. But to operate on someone and, when your shift is over, you go home, and if there is a problem, you're leaving that patient with someone who didn't operate. Then you're backing out of this contract."
Bertrand Bell has heard such arguments before. Often, in fact, since he first headed the Bell Commission. And he calls the reasoning "palaver."
"Here's what the story really is," says Bell. "Graduate residents are in an educational program. The person who gets paid to take care of the patients in the hospital is the attending doctor; he's responsible." He also adds that the Bell Commission focused more on supervision of residents than on work hours, although the latter issue has attracted far more attention.
"Not only can't you expect people who are chronically sleep-deprived to do well, you can't expect people like that to learn and be empathetic," he says, noting some studies that suggest residents have higher rates of depression, drug abuse, divorce, and early labor. "You want to have people who are lovely and pleasant and want to help the world, and at the same time have the support to do it," he says.
But veteran surgeons such as Ricotta and Lillemoe say that stricter regulations such as Code 405 are what send the wrong message to their trainees.
"Part of the training process is building into the residency the responsibility that goes with being a surgeon," says Lillemoe. "If you're undergoing an operation, you don't want a surgeon who says, 'It's 5 o'clock, time to go.'" That might mean sticking around for several hours following an operation to see how a patient is faring.
Critics have spoken harshly about the "hazing" aspects of resident training. And Ricotta admits that some traditions (such as requiring residents to attend daily rounds even on their days off) have rightfully been dropped.
But to the degree that such traditions instill in residents a sense of commitment and dedication and esprit de corps, they serve an important purpose, he believes. "It makes you understand that when you operate on a patient, you really enter into a sacred contract. It's a manifestation of an extraordinary level of commitment that comes of taking care of somebody's body."
Residents should learn, says Ricotta, "you don't abdicate your responsibility to your patients because it's inconvenient."
Ricotta says that the attention generated by the Libby Zion case and Code 405 "has raised the consciousness of surgeons to the physical limitations of residents. We're much more likely now to say to a resident, 'You've got to be tired, take a rest.'" The emphasis is shifting from "how tough you are," he says, to "what's best for the patient." However, Ricotta says the mistake is to take the responsibility for that decision out of the hands of the doctors themselves. "Our concern with the law is that it belittles the responsibility we have to the patient. Being a pieceworker is now what the doctor/patient relationship is all about."
To many longtime physicians, the time clock is emblematic of an
unwelcome transformation of American medicine. Stricter
regulation of their work schedules contributes to their growing
lack of autonomy.|
"We are now training doctors in New York state who will be comfortable working in an hourly wage setting, but not in the traditional practice of medicine as it has been in the United States during this century," declared Ian Holzman and Scott Barnett, pediatricians at the Mount Sinai School of Medicine, in the March 2000 Mt. Sinai Journal of Medicine. "We are concerned that this may sever the bond between doctor and patient--a bond that has been the bedrock of our conception of a physician."
One would like to think that there is common ground in this debate, which would be that all parties are aiming for the same end: the best care for patients. The difference, then, would be in achieving that end through externally imposed rules or a system that leans toward self-regulation.
It may be this ideal, call it the altruism quotient, that will continue to attract young people to the field of medicine, even as other aspects of the calling fluctuate.
"If you decide to become a doctor, you're not going into it for the money or the hours," says Hopkins's Susan Mani. "You do have some higher goals: love for the human body, or you want to answer scientific questions, or you want to help people.
"But you realize a bit more is required of you, that there are times you'll miss certain family obligations. It is a bit like hazing, but you put up with it because you know there is a reward at the end of it."
One day recently, Nita Ahuja had just finished caring for a 19-year-old who had been admitted to Sinai in the middle of the night with multiple stab wounds. One wound came perilously close to his liver. Another penetrated his chest and may have ruptured his pancreas, spleen, and other vital organs. "This guy was almost dead," says Ahuja.
Long into the night, she operated on the man, and finally, by daybreak, she had stemmed his bleeding. One week later, he was discharged from the hospital.
Ahuja also recently operated on an elderly woman who had a large tumor in her stomach. "She had lost 100 pounds," she says. "She couldn't eat. The tumor obstructed her stomach. We took it out and she is going home today.
"Surgery is a very demanding career," says Ahuja. "Demanding, but very rewarding. You never get used to the sleep deprivation, and some days you are ready to call it quits. But seeing patients get better is very exciting. Those rewards are just incredible. I'm very grateful. It's a great job if you're up to the challenge."
Melissa Hendricks is the magazine's senior science writer.
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