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How Much (or How Little) Should Doctors-in-Training Work?

Aaronsingh72x721_2Aaron Singh -- It's funny sometimes how raw materials at the beginning of a process differ so starkly from the end product. One of the most well-known examples is of course the diamond-making process; raw carbon isn't much use to anyone, but throw it through extremes of pressure and temperature, and you get one of the most sought-after gems in the world. And any medical type can tell you that faeces looks quite different before it goes through the process that makes it faeces. Another process medical types can tell you about is the process that made them medical types in the first place: medical school.

The beginning of the whole process is actually quite fun to watch (especially if you're one of those sadistic medical school professors prone to rubbing your hands together and cackling evilly). You've got these triumphant, smells-like-teen-spirit types fresh out of the long slog of school, waving their successful applications about and actually believing in those big terms they used in their personal statements; terms like 'vocation' and 'calling' and 'service to mankind'. Full of bravado, they march eagerly through the gates of med school, completely oblivious to the fact that said gates are painted blood red, ominously tipped with barb wire, and are held open by grinning succubuses in white coats.

Fast forward five or six years and you see the end product. Call them what you will, interns, F0/F1 doctors -- I'm going to call them housemen because that's what my local hospital calls them. The housemanship years, the formative years of every doctor's career, often are also the most abusive and overwork-filled years. The treatment of housemen varies from country to country. Let's look at one end of the spectrum by starting with Malaysia, one of the more advanced Third World nations, a country gaining more and more international prominence for its medical standards.

For years, housemen here have worked 34-hour shifts without much remuneration and not even the reassurance of having the next day off. They are expected to work these hours whilst being given the most menial of tasks and being treated with less respect than the average hospital janitor. This whole baptism-by-fire approach tends to be supported by old doctors (who of course had to go through it themselves) and by young doctors whose parents are old doctors. "You'll gain invaluable experience", they say. "No better way to learn the trade." And when pressed with persuasive arguments, they go back to the old favourite, "We went through it, so you bloody well can too. Knuckle down and stop complaining, you young upstart".

Now let's look at the other end of the spectrum: new doctors with too light a workload. For this, of course, we return to Glorious Britain, Motherland of Political Correctness and People Who Sometimes Just Whine Too Much. Here the European Working Time Directive has doctors working only 56 hours per week, with plans to reduce this to 48 hours in the next few years. And yet still you get protests; predictably from old doctors but also from some very worried young doctors. "How are you young whippersnappers ever going to be as good as we are when we worked hundreds of hours longer than you did?" ask the old doctors. "How are we ever going to be as good as them when they worked hundreds of hours longer than we do?" ask the young doctors. The authorities, of course, sidestep the whole issue by feeding an easy-to-understand analogy to the people. "Just as you wouldn't want a pilot who hadn't slept for two days flying your plane, you wouldn't want a doctor who hadn't slept for two days treating you", say they. And they have a point. But can housemen's workload be reduced so drastically? Will this impair Britain's ability to compete with the rest of the developing world when it comes to healthcare? And just how much (or how little) should junior doctors work? Where is the balance between experience and overwork?

I don't know. All I (and countless other junior doctors like me) can do is look to the Powers That Be to decide what's best for us, and keep our fingers crossed when we graduate.

December 19, 2006 | Permalink


48 hours? Are you serious? I can't even fathom how you would learn anything with that atmostphere. That's four typical days for me, as a fourth year medical student. I know I'll rue the day I said this (next year, likely, when I'm in the midst of the "80 hour" work week here) but I think the long hours are the only way the training can be done. Sure, it's been hellish so far and it's only going to get worse, but to effectively cope with the stresses of life as an attending, I think we probably need to experience stress while someone is watching over our shoulder to catch mistakes.

And I'm the first person in my family to become a doctor.

Posted by: Nathan | Dec 20, 2006 11:56:31 PM

Dear Nathan, can't agree with your 'long hours are the only way the training can be done.' What sort of training is one receiving when you have been awake for 32 hours, with 2 half-hour breaks in toto. How much can your addled brain process? We survive, most have. But I don't think our survival is the ultimate objective. That should be the patient's welfare. And no one provides good 'service' after 30 hours of effort.

Posted by: huajern | Dec 21, 2006 6:26:56 AM

OK, let's get this straight. If you're a lorry driver and you work more than your set hours, the DVLA and police come looking for you with malice aforethought, to take away your licence. This is because a person working too long gets tired, tired people make mistakes and mistakes cost lives.

If you're a pilot, same thing goes. You have a permitted workload which you cannot exceed on pain of loss of licence, for just the same reasons.

Now look at doctors. They're dealing with people right on the edge of life and death; lives are literally in their hands a lot of the time. They have a specialised job to do, involving analytical thought, manual dexterity and good memory skills. They are the same physiology as professional drivers and pilots; the same rules apply, they get tired and make mistakes when tired just like everybody else.

Now, explain precisely why we should not treat the skill of medical doctoring exactly the same as the skill of aircraft piloting, and impose specific hours on these people, for the good of their customers?

So what if the older generation of medics did this? That was then, this is now and right now we know better about working people into the ground.

Posted by: Dr Dan H. | Dec 21, 2006 7:41:35 AM

I don't disagree that working 32 hours shifts is pretty insane. However, as far as I understand the residency programs I applied to, you are permitted a maximum of 24 hours straight of patient contact, and though you may be required to be in the hospital longer, (up to 30 hours) that last 6 can only be spent doing paperwork. If you only worked 8 hours a day, six days a week, like those numbers imply, you'd miss a huge amount of learning. I don't buy the idea that you can learn as effectively from a book. Reading about pertussis is one thing, it becomes a tiny fact in the back of your mind. Seeing a 5 year old kid in extremis from pertussis stays with you forever. I'll never again forget to ask about vaccinations.

The point I see behind this is that one day, any of us might end up being the only doc at a very overworked site, and unless we're used to working while tired, we will be less effective. I don't deny there's a hazing element to it as well, but it makes the medical profession more cohesive, I'm sure, just as boot camp binds together the armed forces.

In order to accomplish the training in a timely fashion, we going to have to spend a lot of time in the hospital. That's why it is called residency. The only option left if we reduce work hours so drastically is to extend the time over which a residency is done. And I would rather suffer through three years of internal medicine than six before starting a fellowship.

Posted by: Nathan | Dec 21, 2006 9:22:53 AM

Sorry, my first paragraph has an unclear refernce. "Those numbers" refers to the 48 hours a week numbers, not to those of my residency program citation.

Posted by: Nathan | Dec 21, 2006 9:24:23 AM

Back in my day, old chap, I worked a one in two on call. That meant 24 hours every other day. Did I suffer? No, I am perfectly sane, I am on the ball, I am sharp minded, decisive, brilliant in every decision. I never forget a patient and I never make a mistake. I am utterly flawless. The voices tell me that I can do no wrong.

Now, where did I put my slippers, its time for my nap.
Prof Scrub

Posted by: Prof Scrub | Dec 23, 2006 8:15:43 PM

Dr Dan H hit it right on the head. I used to rescue people via helicopter. Being aircrew is a physically and mentally demanding task. There were time limits that we could not exceed with out specific authorization form the top brass. 6 hours was out limit and the only way to extend that was to land with 5:55 on the clock, refuel, and fly until that tank was gone (about 4 hours) which was a dodgy proposition at best. There are better ways to train people. There is no support for scholastic sadism over other techniques. One could argue that if we never left the hospital then we would be ever ready to attend to any unique or mundane occurrence. This logic falls right into working too many hours in a week. I say that they should extend the residencies and other training if it is so important. Just my humble opinion.

Posted by: Mike | Dec 26, 2006 5:03:41 PM

I often say that much of the problem of overworked students rests with the students. If enough students were to rise up and demand more reasonable duty hours, something would be done--the problem is that most will just take it all on the chin and not say a word, believing that "if others could survive it then we can too". Perhaps that is true, but huajern is dead right: survival is not the objective, patient welfare is, and other professions have duty limits for a reason. Medicine, for all its supposed nobility and compassion, has managed to overwork its junior representatives for far too long, and it is time for a change; the 80 hour work week is often ignored and even if it were honored to the letter, it would still be too much. How are people supposed to lead even remotely balanced lives, spend time with their spouses and children if applicable, and stay in good physical shape while working an average of almost fourteen hours a day, six days a week, for years? Would any of you doctors/medical students recommend that your patients work 80 hours a week or more? If so, I hope your patients have VERY easy jobs that are more like vacations, because that is far too many hours. The courtesy of the 80 hour limit is not extended to students as far as I know...I can see why this may be, and a common argument against student duty hours is "students are paying tuition, they should be able to learn as much as they want to by staying as long as they want to". Fine, let the masochistics stay, but do not require that of everyone.

A key assumption of long duty hours is that the amount you learn is proportional to the time you spend in the hospital. Unfortunately, too many are still holding onto this claim which goes against all common sense. Unless you're divine, you WILL get fatigued, and most people lose considerable productivity well before working 30 hours straight. Someone up for 24 straight hours is much like a legally intoxicated individual, the research says...who'd want someone in that state making delicate decisions or wielding a scalpel? You can argue all you want about sleep deprivation affecting simple decisions more than complex ones, but operative technique has been shown to be much worse following call nights.

If patient safety is to be our priority, we must stop acting as though sleep is an expendable commodity.

Posted by: David | Dec 26, 2006 10:53:25 PM

Nathan let me know were you are going to be working and I will stay away from your hospital. You can experiment with your exhausted mind on some one else!

Posted by: Ben | Dec 26, 2006 11:30:33 PM

I don't believe that students aren't rising up because they believe that if others survived, then we can too as David says above. I think it's more a reflection of competition - students are afraid to rock the boat. I know I sure was when I was in med school. We were constantly under threat of that cut-throat system - cut-throat professors, cut-throat classmates, the whole weeding out phenomenon - graduating fewer students then began med school.

Training has different goals then patient care. Though of course training is very important, if it involves patient care, the ethics of patient care have to have higher priority. Our first responsibility is to first do no harm. After inhumanly long shifts, we are doing harm, and even when we are not, we aren't doing our best. Patient care is our primary responsibility, training second. If the residency must be extended in order to adequaately learn patient care while delivering healthcare in our best form, so be it.

I also don't buy that cliche that we have to put in those long hours in order to learn it by rote. Repetition will do that, but repetition does not all have to be crammed into a 32 hour shift followed by rounds. It can be stretched out over longer periods of time. Any social scientist will tell you that the learning curve decreases after a certain level of fatigue and errors increase. To continue working after that is harmful to the physician, harmful to the patient and to the whole medical system.

Posted by: Felicia | Dec 26, 2006 11:54:31 PM

I am a nurse. I see 'doctors' after 20 hours up. I see dead people.

Posted by: Victoria | Dec 27, 2006 1:24:06 AM

I think the best way to look at this is by always treating patients how you would want yourself or your family to be treated. I, for one, do not want to be in the hands of tired interns and residents unless it's an absolute emergency. After 9 years of medical training, I'm convinced that a good balance of on-the-job training, time to read, and time to be with your family, god, etc. makes for a much better doctor than a cut-throat, tired, unhappy, overworked resident. To Nathan: stay away from me.

Posted by: Paul | Dec 27, 2006 9:07:53 AM

in my opinion the idea of work hours is entirely flawed. there is too much person to person variation when it comes to stamina (mental and physical).

Considering we are ultimatley concerned about the health and well being of our patients and of our housestaff (ideally), shouldn't we enact personalized work hours based on what each housestaff is able to tolerate with ample buffer to prevent against reachign the tipping point when one becomes a danger to patients.

Of course this system could be undermined by less than honorable people.

Posted by: jesse | Dec 27, 2006 10:24:49 AM

I agree with most of u all that a tired brain is a lousy brain. Doctors need that thinking process to come out with the best and most accurate diagnosis.
When u start working more than 12 hours non-stop without interval break , most of us would be physically as well as mentally drained out , fatigued.
When that happens , there is no thinking process. Every action is a reflex action. U don't care more , possibly just continued working in hope of the "end of the hours" will come so that u can go home and sleep.
Reflex action isn't learning, and sometimes can be dangerous. U make a wrong diagnosis by reflex action and if no senior doc came to check , the one who suffers utimately is the patient. In fact when i was a houseman , during a call , i could fall asleep while doing venepuncture via a vacutainer! That is not RITE!

Posted by: AKS | Dec 27, 2006 7:34:44 PM

Its almost riduculous the way the work hours are reduced. Interns can afford to be overworked, especially since there are the senior doctors overlooking our work. Reducing the number of work hours for Interns means either we need to raise the number of Interns to cover the works shifts, or we need to work the senior staff more to compensate. Since no government is going to spend more money training more Interns, the logical choice would be?
However, a situable reduction is work hours is important for Interns since we need time to do further study outside of the clinical environment, not to mention the fatigue. But 48 hours (8 hours a day, 6 days a week), is almost like a part-time job.

Posted by: Lawrence | Dec 27, 2006 7:48:05 PM

just to side Prof Scrubs, and to inject some balance back into this discussion, it is physiologically possible (studies have been done) to survive work shifts of 80 to 100 hrs a week. Knowing when to sneak in power naps can increase productivity as well. Ask those who have ran ultra-marathons, or done the Gobi march (http://www.racingtheplanet.com)

I once spoke to a obgyn who mentioned that the high workload in the junior years as a doctor makes you much more appreciative of the "easier" life u have in the future when u reach consultant/specialist level.

Posted by: Jeffrey | Dec 27, 2006 10:43:54 PM

I am a House Physician(its so called here in Pakistan) and am working around 80-90 hours a week.Although im much more respected than all janitors, this isnt just enough.Seeing the consultants around having to do absolutely nothing,one wonders how foolish it is to work so long hours.Ultimately most of us are aiming to be consultants;why not be like them from now!!
Answer obviously is that what they are enjoying now is the hard grind they have gone through in their earlier days...and so thats a must for every young intern..
In my opinion,getting it reduced to something like 48-50 hours is just not right...most of us have potential to do much more work...work hours should be reduced to around 60-70 hours just to facilitate acquisition of more theoretical knowledge which certainly helps.

Messge for my professional mates: Enjoy your work and Endure the sweet pain!!

Posted by: Danish | Dec 28, 2006 4:41:45 AM

If your primary concern is to take care of your patients, you should learn to work smart and not hard. Despite how many hours each shift is, you need to learn not to exceed your potential. And while it is unfortunate that some patients may require more time, you can't give what you don't have. And for those control feaks, no one patient really depends solely on just you, and that's that. Learn to delegate the work load, count on medical students, nurses, phelbotomist, social workers, etc, etc...and keep the main thing the main thing. Cause the bottom line is, all your hard work will not pay off if you make a life threatening mistake.

Posted by: Eliane | Dec 28, 2006 11:09:56 AM

In the Dominican Republic, my birth place and home, it's clear that the health facilities are far from optimum. The health care system is in no shape to withstand the lack of interns in mayor hospitals because WE are the base of all daily functions. Unfortunately this makes it easier for attendings and residents to "fall back" on us when it comes to workload. The work hours go from 60 to 70 a week, including when the intern is on call, compared to some of the hours put in by other countries it seems feeble and lazy to complain about such an "understanding schedule" but I say it's not the hours, dough a tired intern is a slow intern is a iatrogenic intern, but more the actual work that needs to be done during these hours.

I had a teacher once tell me: "Don't let them treat you like their personal assistant; you are there to learn and practice, not to be anyone's mule. Do your work not the resident's.” Only now do I get what he meant, Residents here use the term "Intern-automatic" when they intend to leave an area of work and not come back because the interns will "take care of everything".

So I wonder: long hours with less work or short hours and burn-out?

Posted by: Julia | Dec 28, 2006 6:47:43 PM

No one should be MADE to work more than 37hrs a week.People need time AWAY from work to do things that need to be done,also to rest etc.All it does is put peoples mental/physical health at risk both the Dr's and the patients.Atleast they will be less likely to make mistakes and possibly actually WANT to see their patients!!

When I was working "only" 40 hours a week,I never had time to do important things such as keep my car road legal and safe,I rarely had time to relax and kick back,as I was rushing around at weekends trying to get 101 things done that I couldnt do in the week as I was chained up at work,for a pittance too I might add.

People need less hours and more money,companies and institutions need alot more staff,and with alot more staff can see more patients and have a higher turn over.Instead of trying to get a few employee's trying to see as many patients as possible and there still being massive waiting lists and it taking years to get people mended or on the mend.

Sort it out!!

Posted by: Stewart Runnalls | Dec 28, 2006 9:25:37 PM

We are talking about time, how much we young doctors should work. In the perfect world the goal for young and old doctors should be to learn the most we can in any time given to work. And this, my mates, is not based on time, but on quality menthor. I can work only 6 hours a day, one month with good menthor from any medical field and i will know more than working 12 hours a day without or with useless, arogant or unhelpful menthor. I think it is in our and old doctors interest to learn the most we can in any time given, so that we can as quickly as possible become better and experienced doctors in order to help the old doctors with the burden and their work.Anyway, the time is not up to us, but it depends on the political and health system. All we can do is remember this internship years and try to make it better when we will be the "old" doctors, because then we will have the influence on the young doctors and their work.

And, my mates, keep the chin up, internship doesnt last 4ever :-)

Posted by: Dasa | Dec 29, 2006 3:08:21 AM

we reap what we sow.

Posted by: ava ortega,PHL.uph-djgtmedical university | Dec 30, 2006 11:25:33 AM

Clearly, there is a HUGE range of comfort when it comes to work (I know comfort is a dirty word in medicine), and we will never come to an agreement on what the optimal number of workhours is. It seems to me that a few things are obvious: fatigue causes mistakes and experience equals expertise. With these obvious truths in mind, why don't we let the student doctors decide. Certain programs have already extended the length of some residency programs, throwing in "research years" which soften the blow of the clinical years by allowing some residents to get in their hours during the "slow" research year. Residencies should be completed based on HOURS WORKED not on YEARS WORKED. This way, the new mom or the ones who simply do not function well on less that 4 hours of sleep can take a slow track and pull an extra year, while the die-hards who require no sleep can take the fast-track. Maximum and minimum hours per week can be defined by each specialties national colleges, and we can all be done with this nonsense.

Posted by: Heidi | Dec 31, 2006 1:50:07 PM

I'm now in the middle of my 1st year of residency (ie, internship). Quite frankly I'm disappointed in people who complain about the work hours. It is indubitably grueling to work so many hours. But so is training for the Olympics. Great achievements are not intended to be accomplished through comfort and sleep, but rather by pushing onself beyond one's self-perceived limits for a higher cause. Much of our perceived need for sleep is psychological. I use various techniques to help cope with sleep deprivation (including meditation and deep breathing exercises). I also find that a state of euphoria about one's work, one's patients, and the greater good of practicing medicine actually make me able to perform well even when sleep deprived. The shift mentality that exists in modern residency programs as a result of work hour restrictions also leads to less continuity. I learn more, even when sleep deprived, when I'm on the ward working up patient problems (using the numerous online research tools available at our academic center) than I do when I'm well rested at home trying to read.

Most athletes who train for endurance events will admit that much of fatigue is psychological, and a frustrated mindset allows fatigue to set in sooner.

What needs to change is not so much the work hours, but the attitude toward practicing medicine. The self-respect and pride in being a healer ought to be a virtue in and of itself, rather than comfort, work hour restrictions or any of the other secondary reasons for which people become doctors.

Posted by: Sanjay | Jan 1, 2007 9:34:42 AM

The fact is the vast majority of time spent in the hospital is wasted doing scut, writing the same note day in and day out on our long term pts and essentially learning nothing. Let's face it our actual time spent with our pts and being healers is sparse as residents.
As for a previous commenter who stated that he didn't need sleep-let me assure you every one needs sleep. Doctors are no different. Study after study has shown that sleep deprived residents are dangerous and make mistakes. Why does the medical profession fail to see that.

Posted by: Irishdoc | Jan 1, 2007 7:49:33 PM

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