I’m not much of a television watcher. There are collegiate sports and the yearly surfeit of professional bike racing with the European spring classics and the Tour de France and the spectacle of televised American pro sports and all its excesses from time to time, but ridding my household of its televisions would be an easy, albeit unpopular, decision for me.
I have never found the highly popular medical shows particularly entertaining. With a steady diet of disease and doctors at the Medical Center, I don’t exactly feel the need to import more of the same into my living room via cable. Mostly I am struck by how weird and inauthentic the shows tend to be. What makes this compelling television to so many? It is the residents and trainees that the medical shows seem to center around, sympathetic figures that they are in view of the long hours and legendary hardships in servitude endured by these young doctors as they learn to save lives, perform complex medical procedures and battle arcane disease. The dramatis personae seem beset by all sorts of interpersonal situations that make the shows watchable, and the dramas unfold institutionally in settings that bear little resemblance, structurally or functionally, to either contemporary teaching hospitals or residency programs themselves.
They certainly don’t resemble anything I was ever part of.
My residency in internal medicine was short on interpersonal drama among the trainees, long on hours in the hospital, even shorter on sleep and virtually bereft of personal free time. With every third night on overnight call in the hospital, the housestaff would scurry about admitting and transferring patients, tending to developing situations on the wards, consulting with resident colleagues from other services. Contact with the attending service was generally only permitted to move or reassign patients beds, or to notify of a disaster; any call for help would have been considered a sign of weakness.
Interns never slept, sometimes not even finding the time to change into scrubs, indicating their on-call status and whose wearing was prohibited during daylight hours. A few rooms designated for housestaff use were scattered the medicine wards and ICU’s, but residents hardly slept either and would have to defend their actions and clinical decision making to their fellows and the faculty at morning report come daybreak. Fatigue from the night before would descend on the teams as the day began anew, rounds began and clinics were staffed until a new team’s turn on-call began.
The Chief of Medicine’s words, “You can never do enough for your patients,” were enough to motivate even the lazier residents to staying well into the post call day.
It was not a particularly easy time, nor was it by comparison a particularly brutal residency. Some senior physicians were even disdainful, recalling how things were back in the day, when the housestaff were on call every other night and doing it all, drawing blood, performing low-level laboratory tests and transporting patients about the hospital. And so it went. Patients generally got good care, and residents from my program and others like it generally became well trained and competent practitioners of internal medicine and its specialties.
But in 1984, a perfect storm of resident inexperience, lack of oversight by senior physicians, possible sleep deprivation and a complex medical scenario led to the death of a college freshman named Libby Zion in a teaching hospital in New York. She died within hours of her admission, and it was alleged by her father, a prominent journalist (and others) that it was resident incompetence, fatigue and lack of supervision that conspired to kill his daughter.
The Manhattan district attorney permitted a grand jury to consider criminal charges, but the pair of residents caring for Libby were, after much legal wrangling, including allegations of contributory negligence and cocaine usage on the part of the decedent, finally cleared of a raft of charges of incompetence and inadequate care.
Several hundred thousand dollars were awarded the family following a separate civil suit years later. The hospital itself was fined millions of dollars. But it was The System in which we train our residents, reasoned the authorities, not the residents themselves, nor Libby Zion’s illness, her habits or the interactions between the prescribed drugs in her system, that killed her.
Something had to change. The New York State Health Commission established an expert panel to make recommendations as to the maximum number of hours residents could safely work, and what type of backup should be in place to assist them. These recommendations have been generally adopted by the Accreditation Counsel on Graduate Medical Education and exist today. Resident duty hours are now restricted to 80 hours per week averaged over a four-week period, inclusive of all in-house call activities. Residents also rate one day off in seven, “free from all educational and clinical responsibilities.” One day.
This sounds like a lot of work. It is. And these are different times.
Some physicians, myself included, have mixed feelings about duty hour restrictions. There is an abundance of data regarding performance and learning impairment following sleep deprivation, but part of the training in medicine involves socialization to a lifestyle, adaption to the stress of its practice and learning through continuity of care. But I don’t for a moment suggest things were better when I was a resident or that residents become better physicians through suffering.
Dr. Thomas Sporn is an associate professor in the Department of Pathology. His column runs every other Friday.
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