Is there a doctor in the house?
December 13, 2006 8:28 AM   Subscribe

Listening to this story about hospital interns on NPR yesterday got me thinking about the practice of interns and residents working around the clock. What is the purpose of this?

Is there a shortage of interns in this country that they need to work 80 hours a week? Or does this schedule supposedly prepare them for life as a physician? I know physicians are on call from time to time, but is it realistic to think they'd be working 24 hour days back to back on a regular basis? As the NPR story points out, what about the safety of the patients the interns are treating *now*? Is there a doctor here could can shed some light, or are they all too busy working to read MeFi?
posted by Nathanial Hörnblowér to Work & Money (44 answers total) 16 users marked this as a favorite
It's hazing. Although it's well-established that people do not make good decisions if they don't get enough sleep, this is still a practice. Just more hazing from the Good Ole Boy network, as far as I can tell. I don't really want exhausted people who don't have enough to eat and are maybe even supplementing their energy with a little pharmaceutical help treating me.
posted by adipocere at 8:35 AM on December 13, 2006

I imagine if I were a physician who'd gone through the whole 80-hour internship thing, I'd have little inclination to give current interns an easier time.
posted by matthewr at 8:45 AM on December 13, 2006

I'd guess the rationale is "it builds character".
posted by anthill at 8:59 AM on December 13, 2006

The official line I've heard on this is that interns cost hospitals a lot in insurance, so they can't take many on, so they try to get all the work they can out of them.

The unofficial line? Adipocere's got it: hazing.
posted by chickletworks at 9:03 AM on December 13, 2006

I'm not a physician or intern, but I thought that it was to provide 'continuity of care;' that is, being handled by one sleep-deprived person is better than having your case handed off to a series of well-rested (but less familiar with your condition) coworkers. And the hazing factor.
posted by pullayup at 9:09 AM on December 13, 2006

Response by poster: I can (sort of) understand the concept of hazing in a fraternity atmosphere, but at a hospital? It just seems absurd to put patients' lives at stake for the purpose of "making it as hard on them as it was on me."
posted by Nathanial Hörnblowér at 9:25 AM on December 13, 2006

I've heard that its to see if the young docs have the "fortitude" to last through an emergency (like some disaster that injures thousands), though I think that is reaching.
posted by MonkeySaltedNuts at 9:39 AM on December 13, 2006

Part of it, unfortunately, is to condition them to make rapid decisions when tired, fatigued, in foul moods; to become detached.

Their work (in theory) is still reviewed by residents to keep them from killing you.

And once initiated into this system, they feel, that "they" did it..." and so should you.
posted by filmgeek at 9:54 AM on December 13, 2006

Architecture graduate schools have a similar approach, and I think it's supposed to be a hardening process.

Kinda works, in my experience. Architecture graduates have an amazing commitment and work ethos and do very little whining.
posted by StickyCarpet at 9:55 AM on December 13, 2006

The fun part: even as a resident, you get payed by salary. A quite low salary when compared to other technical sectors. When you divide it by the actual hours worked, it makes minimum wage look attractive.

But, then again, the job you are doing is actually meaningful and very challenging. And you have to perform well when it counts, otherwise someone dies. Some people thrive in that kind of environment.
posted by jsonic at 10:18 AM on December 13, 2006

My husband is a resident (an intern is really just a first year resident), and though I'm sure some of it is a hazing/"we did it so you will too" thing, the main reason hospitals schedule residents and interns like that is economic. A resident makes a set salary and gets no overtime pay, no matter how many hours he or she works. So whether my husband was in the trauma surgery dept (working well over 80 hours a week) or in the ER (working 45 hours a week), he makes the same amount of money. You can't say that about regular hospital employees--nurses, PAs or attendings. So a hospital can afford to keep running and take care of patients over night when they take advantage of their interns and residents. Of course, many hospitals could probably reorganize their spending priorities and avoid using residents like this.
posted by jessicak at 10:33 AM on December 13, 2006

Okay, I just read my response to my husband and he added this (which I didn't know): Medicare actually funds residents' salaries, and few hospitals get as many residents as they actually need. A few will fund a few entra positions, but most can't. So they don't have enough residents as it is, so they overwork the ones they have. So i was mostly right.
posted by jessicak at 10:33 AM on December 13, 2006

From what I understand, the patient care decisions made by interns and junior residents are reviewed by senior residents which are ultimately reviewed by the attending doc. So, part of the process is a learning experience (remember: interns are fresh out of med school and do not have much practical experience), and the other part (as alluded to above) is cheap labor for the hospital.
posted by scalespace at 10:44 AM on December 13, 2006

#jessicak: Medicare actually funds residents' salaries, and few hospitals get as many residents as they actually need.

It is not lack of funding, it is lack of med-school graduates.

To keep down competition between doctors, med-school matriculation levels have been nearly constant over the last 20 years, while the US population has grown quite a bit.
posted by MonkeySaltedNuts at 11:02 AM on December 13, 2006

Jesus, I love all the non-physicians in this thread who assert with absolute certainty that the internship and residency hours are related to hazing. As an actual physician, I can say that that's maybe, maybe 5% or less of the reason. Far more important are two things, continuity of care and the sheer lack of funding in this country for more medical trainees.

In terms of continuity of care (as pullayup mentions), giving a patient the chance to have the same physician taking care of him or her through the most acute part of their hospitalization is widely and reasonably considered to be an important thing; admitting an ill patient in the middle of the afternoon, doing all the work to understand the cause of the illness and make plans to reverse those causes, and then immediately handing over care isn't optimal from either a patient care perspective or a training perspective. Here, the key is to make sure that these advantages aren't mitigated or nullified by a medical caregiver who is too tired to either deliver good care or learn -- and that's where the regulations on work hours come in. To date, there are no real studies saying that the current system (24-hour maximum work shifts, 80-hour maximum work weeks, mandatory 10-hour breaks between work shifts) is dangerous, so that system is what we currently have.

In terms of the whole funding issue, jessicak's husband is right on the money -- for the most part, internships and fellowships are funded by Medicare, and there is a limited amount of money in that pool. Trust me, every single residency program would love to double its staff, and cut work hours in half (I say this having been involved directly in medical school and resident training for nearly half a decade now), but it'll never happen in this country, the money just isn't there.

Hope this is helpful, and does something to combat the know-nothing "it's hazing!!!1!" crap.
posted by delfuego at 11:55 AM on December 13, 2006

As for MonkeySaltedNuts's assertion that med school matriculation has been artificially held steady "to keep down competition between doctors", that's also a load of crap, and is in fact an easily-verified load of crap.

First off, med school applications were on the downswing for most of the late 90s and early 00s, for a slew of reasons. It'd certainly be a feat if the Masters Of Medicine were able to achieve their goal of suppressing competition between doctors by cutting off med school applications, but that's highly unlikely.

Second, despite this, med school matriculation has actually gone up nearly 7% in the past ten years -- US medical schools graduated 16,252 students in 1995, and 17,370 in 2006.

God, I love misinformation. Sorry to spawn the tangent off of the comment, but I had to correct its assertion.
posted by delfuego at 12:03 PM on December 13, 2006

Whatever the reasons, it doens't seem like it is worth people's lives.

A couple of years ago one of the Docs at the hospital was driving home from some three day on-call marathon, and she didn't have enough sleep to drive, and whammo, she was severely injured in an auto accident. Luckily she was the only one involved (she hit the median wall, IIRC).
posted by Monkey0nCrack at 12:11 PM on December 13, 2006

Delfuego, the U.S. population has grown about 13 percent in between the years 1995 and 2006, meaning that the number of new doctors per capita is, in fact, declining. The fact that the baby boom generation of doctors is retiring is exacerbating the problem.

The fact that med school application numbers were lower has no bearing on the number of doctors med schools can matriculate, unless you are asserting that there were fewer applicants than available med school slots, or that the people denied admission to med school during that period were so grossly unqualified to be doctors that med schools were doing the public a favor by rejecting them. If I have 30 med school slots open, it doesn't matter whether I have 60 applicants or 80, it only matters whether I can find 30 in the applicant pool who are qualified.

None of this proves that existing doctors are artificially suppressing competition, but the numbers you've presented definitely don't prove that they're not doing so.
posted by decathecting at 12:18 PM on December 13, 2006

Best answer: Let's see if I can think of a list of reasons, as someone who's been through the process and probably isn't very objective about it. I'll refrain from passing value judgments on the process until the end.

1) Hazing. Denying this is stupid. If you've ever been around a bunch of docs sitting around dicksizing over "my Q3 is bigger than your Q3," you can't deny it. I don't know what heaven delfuego claims to work in; but I know when I'm being hazed. Because it's terrible.

2) Serves to weed out people who think that doctoring might be a fun part-time job. It's not a part-time job; it's a serious commitment.

3) Weeds out people with health problems or mental instability, legally. Sleep deprivation is a powerful means of stressing the body and mind, and if there are health problems, it will exacerbate them. You can't refuse someone admittance to med school because they're a chronic depressive or have refractory epilepsy - you might not even be able to know this when they're admitted - but you can certainly accept their resignation when the stresses of the job make them too ill to continue.

4) Continuity of care. Yes, of course, it's much better to hand off care on a patient after a 36-hour shift, sleep-deprived and unable even to recall what happened since the beginning of the shift, than it would be to hand it off after 8 hours of orderly, well thought out medical decision making.

Let's face it. In the ideal world, a physician would work 168 hours per week, never be tired, and take care of a patient for the total of their natural life. That would be perfect continuity of care. Since no doctor can do this, continuity of care needs to be assured by other means. Long shifts are one way; careful sign-out another.

5) Saves the hospital money. Undeniable. I got paid $2.50 an hour in my intern year. If there's more work to do than the residents can do, a trained professional like an NP or post-training MD has to be hired to do it, and that's very expensive.

5a) The number of residency slots doesn't fluctuate by supply and demand; it's regulated by the ACGME, and since a non-ACGME residency spot doesn't fill board training requirements, hospitals simply can't hire people to fill it. So hospitals have a financial incentive to get the maximum work out of the limited number of spots they have been permitted to fill.

5b) A lot of training takes place in institutions like city hospitals that care for the uninsured. The choice is pretty much between providing $2.50/hr care or providing no care for these folks. In general this is a net good for the uninsured folks.

6) Creates a powerful incentive to deliver efficient, focused, correct care the first time without any screwing around, dithering, or needing to come back to fix the mistakes you made the first time. When you've been up 23 hours, the last thing you want is the nurse calling you up an hour later to point out that you wrote an order that would kill the patient, and would you kindly come back and correct it please?

This is another way of saying that it teaches you to make decisions under stress.

7) It's the way it's always been done.

Actually, my prof who trained at my residency program in the 60's points out that rather than Q4 call, he took Q2 call, but the nurses generally let him sleep through the night. I never slept through the night on call; medical technology and understanding has advanced to the point that it's no longer ethical to let a patient sit in the E/D until the morning comes.

Every medical breakthrough that promises improved outcome for a patient when applied in a timely way, however, is a breakthrough that worsens the lives of interns and residents, and the last couple decades have seen a slew of these breakthroughs.

8) It creates a sense of distance from others, of being set apart in a common fraternity. This is part of what being a "professional" means. In theory, this sense of distance is supposed to help us do our jobs; it marks us as a class of people whom patients can trust, and it is supposed to make us more confident in our own skills and decisions.

8a) This is the part where a bunch of people with deep-rooted psychological problems with authority quote the above paragraph and ridicule its assertions, and me and all physicians along with it. Go nuts, folks.


So does it work? Here are my opinions:

It's probably a pretty effective means of hazing; it creates countless opportunities for others to be easy on the people they like and to punish the ones they don't.

It probably does weed out some folks, whose perspectives are then lost to the profession. I don't think this is a net good.

It's terrible for patient care. It's completely indefensible, to my mind. This is why it has to change for the better.

It's terrible for the doctor. Long term sleep deprivation and high levels of stress, cause hippocampal atrophy, decline in IQ, mood disorders - proven facts. 66% of medical interns and residents will be in a motor vehicle accident during the first 3 years of their training. This doesn't benefit anybody, and in fact is probably a great societal harm, all told.

Does it really save the hospital money, and serve as part of the process by which the supply of doctors is artificially limited? Yes. And supply-sider studies have shown that people will consume as much health care as is available; Milton Friedman used to lecture that if left unchecked, health care costs could grow to exceed GDP, because there is no point at which demand would reduce. That's not good for society, but you would think we could find another way to deal with this.

Does it give doctors an incentive to learn and perform efficiently and correctly? I think it does, and I think this is a great value of the current system that would be hard to substitute for. In general, I think the things that motivate physicians are not easily comprehensible to lots of more easy-going folks; the current system is really pretty well suited as a powerful motivator to that kind of person.

So yeah, like anything worth an hour-long discussion on NPR, it's complicated.
posted by ikkyu2 at 1:34 PM on December 13, 2006 [37 favorites]

First off, med school applications were on the downswing for most of the late 90s and early 00s, for a slew of reasons.

This is specious. There are still far, far more applicants than spots. I'd argue that the main reason was that better information for potential applicant candidates, available on the Internet, enabled many applicants to realize that they stood no chance of being accepted. With the fees for application standing around $1,000, simply not applying in that situation makes good sense.
posted by ikkyu2 at 1:46 PM on December 13, 2006

Response by poster: Every medical breakthrough that promises improved outcome for a patient when applied in a timely way, however, is a breakthrough that worsens the lives of interns and residents, and the last couple decades have seen a slew of these breakthroughs.

As though you hadn't provided enough info already, ikkyu2, can you expand on this?
posted by Nathanial Hörnblowér at 2:06 PM on December 13, 2006

IANAD, but I am a frequent patient, so I'll take a stab at Nathanial Hoernbloer's comment. The key here is "in a timely way". If the patient would die (or otherwise have a less acceptable outcome) in a given period of time, then the interns and residents have to be ready to go 24x7. With older medical tech, things were not quite as time-sensitive (because, hey, that guy with the open torso wound is gonna kick it anyway), so there was less of a need for round-the-clock availability.
posted by spaceman_spiff at 2:20 PM on December 13, 2006

Hornblower, it's not complicated. When nothing could be done for a stroke, there was no need to wake the neurologist up until morning.

Now that we have "clot-buster" drugs, the neurologist has to answer his page from the E/R (or anywhere - you never know where the next stroke is coming from), then page a special pager that wakes up 5 people, then literally run down to the emergency room, examine the patient, arrange for the MRI and blood work, check the results, and get the clot-buster drug hung (in the correct dose) within 3 hours of symptom onset. This can happen 2 or 3 times in a night in a busy urban tertiary care hospital.

Which call would you rather get paid $3/hr x 24 hours = $72 to take, Hornblower? The one where you walk down to the E/R in the morning and diagnose 3 strokes, or the one where you are on your feet all night, arguing with night-shift employees to do work they don't want to do while trying to be in 3 places at once?

I suspect that some of my older professors really didn't understand that things actually had changed since they were residents. What was certain is that they didn't care. What was expected was perfect patient care at all times, even if it was physically impossible.
posted by ikkyu2 at 11:00 PM on December 13, 2006

If the hospitals have no money, why is Bill Frist and his family so rich, owning hospitals? Maybe I suffer misinformation, but my understanding is that hospitals (private ones, anyway) are quite profitable.

Ikkyu2: One of your best threads ever. Thanks for being so candid on this topic.
posted by Goofyy at 3:52 AM on December 14, 2006

ikkyu2, what do you mean by "Q3"? I would expect sales people to be bragging that my Q3 is was bigger than your Q3 where Q3 == third quarter of the calendar/financial year.

Q2 is the second quarter of the day? 6 AM to noon?
posted by GuyZero at 8:32 AM on December 14, 2006

med school matriculation has been artificially held steady "to keep down competition between doctors", that's also a load of crap

Medical School Accepted Applicants 1992-2001
1992	1993	1994	1995	1996	1997	1998	1999	2000	2001
17,465	17,361	17,318	17,357	17,385	17,313	17,373	17,421	17,536	17,456
Total change: -.5%

Medical School Matriculants, 1995-2006
1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006
16,252	16,201	16,164	16,170	16,221	16,301	16,365	16,488	16,541	16,648	17,003	17,370
Total change: +2.5%

Notice that without the grudging increase in 2005/2006, the net increase in medical school enrollments since 1991 would be essentially zero.

What effects does this have? As the US health industry expands, it must suck in more and more foreign medical graduates. This is one of the reasons why the ratio of doctors to population is so low in many countries - a huge proportion of their graduates emigrate to the US. These countries therefore see little incentive to expand spending on educating medical staff because of the high probability that they will simply leave, taking their training elsewhere. The US thus effectively off-books a huge education budget, often shifting the burden onto the poorest countries of the world.

As regards continuity of care, this is of course important. But medical journals are now increasingly full of studies analyzing at what point sleep deprivation tends to kill and injure more patients through physician error and lack of empathy than errors introduced through shift handover. And there is the problem mentioned above of the high mortality and injury rate among interns and residents from vehicular accidents and workplace incidents.

I have yet to see many convincing papers that demonstrate that EU interns and residents kill more patients because of increased transfer rates due to their work hours being fixed at a much lower threshold than US interns and residents. Ideally, these are currently 58 hours per week max, and no more than 11 hours per day. One effect of implementing the new short hours (decreasing to 48 hours in 2009-20012) is a committment to a proportionate expansion in matriculating doctors.

The Nordic countries have long exceeded these restrictions with much shorter hours-per-week and maximum shift hours. Maybe someone can find out how this affects patient mortality and outcomes?
posted by meehawl at 9:45 AM on December 14, 2006

I would also just like to point out that not all post-medical-school training is as heinous as you see on television. In certain fields, you work an almost normal schedule. I graduated from my residency in pathology recently. During residency, I never:
-slept in the hospital
-stayed later than 9pm
-worked more than 60 hours a week

But, then pathology (and a few others like radiology) is a 'lifestyle' specialty. We took call for a week at a time, but this is pager-call. Most of the pathology call is related to the blood bank (which we supervise). This is by no means difficult; mostly you have to monitor your platelet inventory. Every great once in awhile, we have to come in on the weekends for emergency cancer surgery (to render diagnosis for surgical management). For the most part we have our weekends off, holidays off, and generally have a pretty nice life during and after residency. We make good money and generally work 9-5 after residency. The trade-off is that you don't see patients anymore. But the great thing is that you are going to be involved in all of the great cases that come through your hospital. All of the cancer diagnosis and staging of cancer is our call.
posted by i_am_a_Jedi at 10:00 AM on December 14, 2006

Q2 means you spend every other night in the hospital. There's no way any more to be Q2 in an accredited USA residency program for any length of time; it's now prohibited by law.

Q3 is every third night, and Q4 is every 4th night. These things are approximate and get shuffled around, of course, so that interns and junior residents lose entire Saturdays and Sundays, and chief residents never take a weekend.
posted by ikkyu2 at 1:43 PM on December 14, 2006

Hazing isn't simply maliciousness. It turns out that hazing rituals increase bonding and loyalty to a group or profession.

That's why fraternities use them. It's why some religious groups have manhood rites. It's one of the reasons for "The Crucible", something that Marines must go through at the end of basic training.

It's hard to say why hazing has that effect, but beyond dispute that it does. And the experience has been that in general the more painful and unpleasant and difficult the hazing ritual, the greater the bonding and loyalty it engenders in new members.
posted by Steven C. Den Beste at 1:43 PM on December 14, 2006

If the hospitals have no money, why is Bill Frist and his family so rich, owning hospitals?

Bill Frist, or HCA, which is the business he's associated with, doesn't own many academic medical centers. That company doesn't shoulder the cost of educating residents and its hospitals, by and large, don't provide care to the uninsured. It's operating, if you will, in an almost entirely different sector than the academic medical center.
posted by ikkyu2 at 1:49 PM on December 14, 2006

A Case That Shook Medicine: How One Man's Rage Over His Daughter's Death Sped Reform of Doctor Training

In 1989, New York state adopted the Bell Commission's recommendations [a study the state ordered after a lawsuit involving the 1984 death of a depressed woman with unfamiliar symptoms] that residents could not work more than 80 hours a week or more than 24 consecutive hours and that senior physicians needed to be physically present in the hospital at all times. Hospitals instituted so-called night floats, doctors who worked overnight to spell their colleagues, allowing them to adhere to the new rules.

Still, some physicians resisted reform efforts. One simply could not become a qualified doctor, they argued, without experiencing firsthand what happened during the often unpredictable first 36 hours of a patient's illness. Critics attacked the night-float system, arguing that the constant trading off of patients among physicians would impede care. Many institutions essentially disregarded the new regulations.

Until 2003. In that year, the ACGME made reduced work hours mandatory for the accreditation of residency training programs across the country. The new ACGME standards look remarkably similar to those of the Bell Commission.

Now it is commonplace to see chief residents at medical centers charting the numbers of hours worked by their staffs. Residents who wish to stay longer at work are at times sent home to sleep, a development that would have been inconceivable in the past.

As might be expected, the new requirements are a work in progress. A study published in the Sept. 6, 2006, issue of the Journal of the American Medical Association found that 80 percent of interns nationwide still sometimes work excessive hours.

posted by dhartung at 5:01 PM on December 14, 2006

Everything about medical school, from the ridiculous standards, to the outrageous application fees, to the shocking expense, to the brutal exploitation of students, to the artificial class size restrictions, is purposely designed to depress the supply of docs.
posted by Ynoxas at 9:12 PM on December 14, 2006

As a side note, if someone you love is in the hospital, one of the best things you can do for them is provide more continuity of care. If a new nurse or doctor comes in, act on the assumption that the previous shift failed to brief them on any critical or unusual details in you loved one's condition. Night nurses may not know that some patients shouldn't be move; new doctors may change treatments when the old treatments were unusual for a reason. (E.g. you know, and the previous doctor knew, that your grandmother is unusually responsive to drug X; new doctor assumes that since the X levels in her bloodstream are low, she needs a higher dosage). Between shift changes and exhaustion, a lot of information gets lost in the hospital system; having someone watching for it can head off a lot of avoidable errors.
posted by grimmelm at 7:50 AM on December 15, 2006

A Case That Shook Medicine

grudging increase & kill and injure.

But you're right, it does bear repeating.
posted by meehawl at 1:07 PM on December 15, 2006

Brilliant, articulate, interesting and juicy comment ikkyu2. It's a question that bothered me for years. Thank you for taking the time to explain the nuts and bolts of the situation so well.
posted by nickyskye at 6:52 PM on December 16, 2006

I can see from the heatedness of this discussion that this issue clearly hits home and for many reasons. As one of the few actual *doctors* reading this (I am an attending now, but fairly recently completed my residency), I hope that I can shed some light. I agree with the other MD who posted here that the major reason is, indeed NOT hazing, but workforce need and finances.

I'll say it again: I am a doctor in the United States. I did an actual internship and a residency. I applied to medical school during one of the highest-application years in history, shortly after which applications to US medical schools dropped over the following ten years. The above poster who mentioned this was correct, factually. The reason for the numbers of doctors training in the US being inadequate to meet the actual need for trainees IS NOT TO PREVENT COMPETITION AMONG DOCTORS, in my opinion. That is an insane allegation. I would like to point out two things that have not yet been brought up:

1) more housestaff are needed than attendings. The problem is that housestaff eventually graduate from their residencies and become attendings. If we were to just expand the number of residents without somehow altering the system, we'd

A) have an excess of attendings AND

B) all of those folks who had been working 80 hours a week for about 40-50K per year (mind you, this is after ten years loss of time from the workforce and with a zillion dollars of loans for most) get to work 40 hours a week for half the pay (thus unable to pay rent in this town) and likely have to train longer (as a result of having seen half as many cases during postgraduate training)


2) It is HARD to be a doctor. This is not simple economics ruling the supply and demand chains here, as was effectively alleged by a poster above. I went to a top-tier medical school in the United States, and despite the very strict selection criteria, there were people in my class who just couldn't manage the workload. We can't just lower the standards just to make more doctors. Honestly, most of the people whom I have met who didn't get in shouldn't have. This is something that for some reason isn't cool to say. But it is true nontheless.

Academic hospitals (and I trained in Boston, so this is the LEAST medically underserved area of the USA) are understaffed at the "houseofficer" (doctors who are interns and residents) level. There are a number of reasons for this, but I think economics is the major reason. Indeed, some of the moment-to-moment work currently done by houseofficers could be accomplished by nurse practitioners or physician's assistants, but where would the funding come from?

I know that when I was a resident, I would have preferred to work an extra few hours than sacrifice another year of mylife to the altar of medicine and simultaneously cut my pay...

Hazing is not the issue. I think most physicians understand that the system is broken and that there are probably better ways around the problems at hand. Solutions are beginning - I know that I worked under strict rules surrounding the work hours, and my training program had begun to use PA's for academically uninteresting cases. We all want the learning experience to be excellent for our peers (and future replacements!) without sacrificing patient care nor physician quality. To imply that this is a system motivated by purile hazing is uninsightful at best.

So why don't our country's bioscientist best and brightest want to be physicians? Whelp, after ten years in college, and another four years doing the labor of two ordinary people for half their pay, I finally have a job, for which I am underpaid and pay staggering malpractice insurance... I should have been an attorney if I cared about money. I work really hard. Lots of my patients are nuts, or noncompliant, or just annoying. I still work ten hour days and cover my own call 24/7. When eager-eyed college students ask me about becoming a doctor, I always tell 'em the same thing: if you can imagine yourself feeling satisfied doing anything else, do that other thing.

Sorry, but the issue here is a lot more complicated than just "ohh, they work too many hours in a row" and to call it simple hazing is an insult. To imply that this is somehow about controlling a marketplace is disrespectful. Let's be a little more broad in our thinking, here.
posted by reddot at 2:22 PM on December 17, 2006

Offtopic, the top three questions that will save your life in a hospital are:

1) Who do you think I am?
2) What do you think is wrong with me?
3) What are you going to do about it?

If you ask these of anyone giving you medication or treatment, you will eliminate at least 80% of medical error.
posted by anthill at 12:40 AM on December 19, 2006

This is not simple economics ruling the supply and demand chains here

I am afraid it plays the most significant portion ; I am not completely aware of the costs sustained by a student that wants to become a doctor, but I am told the doctors have very significant college loans, which implies

1. they didn't have money to pay for the expenses to begin with

because no matter what your financial "consultant" (my collegues, they are hyenas) will say, borrowing money is expensive so there is no point in not paying immediately, unless you plan not to pay

2.the extra cost of loan needs to paid back somehow and the loan must be paid as well

which is a very strong incentive to do the best, work hard, triple quadruple shifts or whatever, because otherwise you will not be able to pay the loan and fail miserably

So what some of my sharks...I mean dear colleagues, might have understood is that they have a quite good workforce, working for dirt money, motivated to learn, heavy in debt and only an handful of them will make it to the top ; insurance companies also love to a rather large population of doctors or wannabe doctors, as long as they pay.

As they move to the high retribution level, the competitions sets in so their price is kept reasonably low , but as they are accessible mostly to well insured or privileged patients, they become cash machines.

Or so it seems from here...the bottom line still seems to be 23h shifts are inhuman, dangerous for the patient and the doctor, pointless. I guess they need the delusion that this kind of experience "forms" them better than a regular 5-6 days 12h shift.
posted by elpapacito at 5:27 PM on December 20, 2006

borrowing money is expensive so there is no point in not paying immediately, unless you plan not to pay

Wrong on both counts.

a) My med school loans barely kept pace with inflation - I believe they're running 3.25% since I consolidated. If I'd invested the money, I'd have made a tidy profit. Med school loans are one of the many perks society hands to physicians.

b) There are many, many legitimate ways not to pay your med school loans, at least here in the USA - i.e. to have some other agency pay them for you. Off the top of my head I can think of:

1) Joining the armed forces as a uniformed physician. Your med school debt disappears.
2) Working in an underserved area for a few years, called the PHS (public health service) program.
3) Completing an MD/Ph.D. program, or the Medical Scholars Training Program, or somehow otherwise assuring the NIH that you'll do research in the future.
posted by ikkyu2 at 6:48 PM on December 20, 2006

Yes, but all your options are : more working. If for some reason you can't work and that doesn't necessarily imply negligence or lack or skill, what happens ?

Ironically, what happens to a sick/disabled doctor ?
posted by elpapacito at 8:35 AM on December 21, 2006

I’m applying to residency too and I’ve noticed lots of programs openly admitting that the old system used to kill people and many progams have 7:00-5:30 days and long call till 9:00 q4 but keep overnights in the ICU (where its desired). Of course, none of the big names are moving to such sensible systems but oh well….

The comment about medical technology making things harder for a resident I’m not sure about though. Before, say someone had a possible pneumonia. You’d have to weight for them or hope they could withstand a non-portable chest x-ray. You’d have to wait for the film to be developed. You’d have to walk to radiology and analyze it under a light. If you suspected a bacteremia or something urinary – you’d often have to plate it yourself. If you wanted to know the past medical history of the patient it meant lots of calling and faxing (unlike electronic records today even they are not comprehensive). MY GOD, most hospitals have staff for blood draws, placing IVs, etc. (all the area of “medical expertise” of the past overworked physician).

In short, a 2006 resident is vastly, vastly, vastly, vastly, vastly more productive than a 1966 resident. Why should she have to stay in the hospital as long?

Nurses have access to TONS more information today as they even read online journals and use the internet to learn more patient care.

They work you that hard because you are extremely cheap labor. My father is a doctor at a community hospital that has no residents and I see how much he works versus the attendings at hospitals that have residents (even community ones). His hospital is trying to get residents for the sole purpose of keeping their medical staff happier (not to educate newly minted medical students).

The only point to staying in a hospital is perhaps to see disease progress and recover. In surgical fields, I can understand that as the post-operative period is so critical. In medicine, I can’t see it as much. What, I have to sleep in a crappy bed overnight answering questions as to whether patients should get Tylenol just to see someone’s O2 sat go up? No, I’ll see that on night float and I can hear about in the morning.

In the Northeast, Harvard, Columbia, Mount Sinai, NYU, and Cornell (the big names) still have overnight call in medicine on regular floor months. Mostly every other place has changed. Why? Because being awake for that long making important decisions about sick people kills people.

After an overnight shift, I often try to test my recall on the most basic drugs and their mechanisms or even simple trivia like who sang what song. My performance is piss poor. After a bit of sleep, I’m ready to go again. I have no clue why I should be working under that state.

Also the comment about the doctor supply needs to address foreign graduates of which there are about 10,000-15,000 each year that enter residency. The Caribbean churns out tons of M.D.s from American kids who for whatever reason were not able to get into M.D. programs in the states. Tons more come from all over the world and are “foreigners” in a truer sense. Moreover, I think the osteopathic schools kick out about 5,000+ doctors a year too.

Ikk, I’m not sure about the “weeding” out need though. I think medical school and the licensing exams handle.

As noted, Europe handles residency VERY differently. 40-60 hour work weeks, but longer training terms. Oh, and their people are living longer than ours as well. (And more of them smoke like chimneys……go figure). Let’s not quote studies that dubiously address causation.
posted by skepticallypleased at 11:41 AM on December 21, 2006 [1 favorite]

Ironically, what happens to a sick/disabled doctor ?

Is this a serious question? Most docs carry disability insurance. I know a number of docs in wheelchairs; I knew a urologist who used to stump around on a peg leg, eschewing the more modern prosthetics.
posted by ikkyu2 at 11:39 PM on December 24, 2006

Thanks Meehawl for looking up the stats on how dangerous the longer shifts are. Q4 is a 1:4 rota here in the UK and getting rarer by the minute as phase 2 of the European Working Time Directive approaches (by 2009 all docs will have to work a maximum of 48 hour week averaged over 6 weeks) 11 hours rest in a 24 hour period is mandatory. The stats from our European neighbours where they are in theory working these hours is that patient care is not impacted. Although I have yet to meet one European doc who is actually working a 48 hour week.
My job is looking for new and innovative ways to train surgeons in these reduced hours circumstances, getting away from the apprenticeship model where they spend 100+ hours on a Q2, towards a model where their service commitment is reduced and they actually just get to do the stuff that adds to their training.
I can honestly say the morale among surgeons in the UK has never been lower.
Between Modernising Medical Careers and EWTD Because of the craft nature of the specality there is a certain limit below which the hours cannot go in the current system, since they currently don't hve access to other mechanisms for perfecting their skills.
Yes it was appalling that it took 15 years to routinely finish your specality but most trainees here are on comparatively good salaries and most were guaranteed a job for life in the NHS on completion.
But the times they are a changing.... thanks Ikkuyu2 for the insight into the USA situation
posted by Wilder at 2:51 AM on January 4, 2007

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