True Grit

Many of you would have been uptodate with the news in Malaysia about the hardships that a House Officer has to undergo. The firestorm stems from the tragic death of a young doctor who died from allegedly using medications to fight fatigue.

This was then followed by numerous complaints and letters from HOs, and even their parents (yup, you read that right. Parents) about the inhumane work hours of the trainess.

As expected, this was followed by the kneejerk reactions from the authorities, including mandating that hospital directors meet with the HOs weekly to discuss their welfare.

Work-hours. It's a double-edged sword. It's an issue that is arising in Malaysia, but one that has been troubling program directors and residency/fellowship programs for the last 8+ years here in the US.

It's common sense. An exhausted doctor can be a dangerous doctor. How many of us can attest to making a mistake when we are exhausted? As a resident, I've had postcall days that I couldn't remember where I parked my car, and walked home instead. Or when I couldn't remember a friend's phone number. Or what I did with a patient's orders. I remember Buddy's story of how he fell asleep whilst dictating a patient admission note (he had 5 mins of silence that he had to rewind through to resume his dictation!). And you want me to stick that big-ass 18G needle into a patient's belly after I've been awake for 32 hours???

After all, who amongst us would want our family members to be treated by a doctor who's been awake for the last 28 hours? Hell no.

There is data to support that too. Probably also stemming from the pivotal but tragic case of a patient death related to a medical error that was attributed to intern exhaustion. Over the years we have seen numerous publications in the medical literature on this topic, finally causing the ACGME to restrict resident work hours. And thus, when I became a senior resident, our interns could work no more than 30 hours at a stretch, and 100 hours in a week. Naturally, the seniormost people had to pick up the slack.

More recently, the Institute of Medicine published some recommendations to limit things further. This includes

• Limiting the work-week to 80 hours
• Limiting the shift to 16 hours
• Giving protected naps for extended shifts
• And reduced workloads especially for interns

While this sounds fine and dandy, this opens up another can of worms. What then would be the implications of this?

For one, the internship is only one year. It is in that vital, short (well, it felt like forever, didn't it?) year that we learn. We attain the skills to think on our feet. How to make important decisions. How to properly evaluate a patient and formulate a treatment plan. How to balance our time. Prioritize. To be strong, mentally and physically. And it was assuring, knowing I always had a senior to turn to. It is in that short one year, before I am released into the 2nd year of residency at which you are operating semi-independently with no in-house supervision at nights. I learnt a lot in that one year. So, what would be the consequences to the learning then, of cutting the work hours down so dramatically? Will an intern be prepared to fly on his own the following year? And what would happen when the intern who is used to working 16 hours max, goes into the 2nd year and suddenly is faced with longer hours and more responsibility? Is this ex-intern/HO then going to have mommy and daddy complain about the work hours? Are you really going to be able to insert that central line, or do that LP, on your own? Are we going to have an exploding troop of 2nd year green residents/MOs?

An inadvertent consequence many of us foresee then, is that the residency programs will eventually need to increase the duration of their programs.

What about the work? If you reduce one's work hours, how will things get done? Well, when I was the SMuRf (Senior Medical Resident) we did the crap. After all, the restrictions didn't apply to the seniors (do they now?). It would appear this is the case too in Malaysia from what I hear from my colleagues; the more senior MOs end up doing the work.

Another option is to hire more. Have more trainees. Hire hospitalists, mid-level providers, to help with patient care. Which sounds like a good plan until you consider the cost. Indeed, the estimated annual cost of implementing the IOM recommendations was a staggering $1.6 billion dollars.

And so, it's not that simple. You can't just say "Let's cut down the hours, and treat them like Kings".

Though I don't know what the best solution is, I am of the opinion that being a doctor is not meant to be easy. Admittedly I'm probably just being old-fashioned. But the long hours and years mould us to be the doctor, much more than what medical school does for you. I see this as a filter as well, for those who truly were passionate about helping others from those who went into medicine for the wrong reasons.

A career in medicine requires true grit.

And so, if one expects a walk in the park, then that person is going to be sorely disappointed.