I had heard all the stories.  100+ hour weeks, staying up for 40 hours straight, not seeing your family for days.  The thoughts of a career in medicine frightened me.

I also thought it was all ludicrous, the holdover traditions of an archaic, out-of-date and out-of-touch system.  It was all about paying your dues to enter this boy's club.  They did it, so you have to as well if you ever want to be accepted.  I was positive it was another in a long series of hoops that I had to jump through to be a doctor.  I had heard a number of arguments from the "old guard" about why it was important, even necessary, to work those hours.  I thought they were full of it.

Then something happened.

I actually started medical school.

Suddenly I had an epiphany: There is a lot to learn if you are going to be a good doctor.  I mean a LOT.  I don't say this with any sort of ego or pride in my words, but until you actually do the training you simply cannot comprehend just how much information there is to learn.  Not even remotely.

And that learning takes time.  Easily 120 hours a week if you hope to be competent.

So I began to work 80-100 hour weeks.  That is in house (ie. in the hospital/clinic).  Not every rotation demands those hours, but the big ones do (surgery and internal medicine in particular).  The day often started at 6, maybe 5 and even 4 am.  It ended at 9-10-11 pm, only to start the next morning.  Oh, those were the days you actually left.  It doesn't take too many days of 4am-10pm to really start racking up the hours.  You have hit full-time status by the time you go home Tuesday (36 hours), 90 by Friday, and expect at least another 6-10 hours on Saturday (if there aren't too many emergencies).  I was truly amazed at how easily you can work 100 hours/week.

Yet what amazed me more was that I felt I needed to be there more. 

And I have never been a "gunner".  Those are the guys who always sat on the front row, studied every single night for the upcoming exam, answered every question, and just basically pissed off those of us who valued our lives outside of school.  Still, I felt I was running short on the time necessary to learn what I needed to.  And so, against my inherent laziness, I staunchly stand in defense of the 80 hour work week. 

I agree that more than that is too much.  It doesn't take long to be running on fumes alone.  But, yes, 80 is perfectly reasonable, and even necessary, if you are to learn what you need to in order to practice medicine on your own.  This is particularly important for us surgeons.  Not only do you need to learn all the pathophysiology, you need to learn how to operate as well. 

That doesn't come easy.  You can read about how to do a procedure a thousand times, watch it a hundred times, but until you have done it, at least dozens of times, with some supervision, you ain't ready to get out there and do it on your own.  And that practice comes at a heavy cost of time.  After four years (at least) of undergraduate work, followed by another four of medical school it just isn't reasonable to expect us to be in residency for 9-12 years.  But, in the case of my specialty, I would have to in order to get the same amount of learning in.  80 hours is too much?  Cut it back to 60/week and suddenly you have to add 1, 2, 3 or even 4 years to each person's residency.  Cut it back more and the problem becomes even worse.

But what about patient safety?  It is the first concern of every (decent) doctor.  And so, yes, that becomes an important matter when we start working so many hours a week.  Of course, with the new rules in place, things are better.  No resident is allowed to engage in actual patient care for over 24 hours continuously.  You can then have another 6 hours of "education", such as conferences, rounds, and hand off.  But that still is a lot.  I agree.

Part of it is conditioning.  If you do it often enough, you get used to it.  You get better at thinking when you are tired.  You double check what you are doing with your co-residents.  You run it past your attending (who likely got a bit more sleep than you last night).  And, honestly, if you are trained well, it is astonishing just how much you can do on instinct. 

So, do long hours contribute to patient errors?  You bet they do.  But what is the solution?  Shorten the hours and suddenly you have to answer the question of who is going to take care of the patients.  What is worse, a hospitalized patient who has a tired doctor there on hand?  Or a hospitalized patient who has no one?  I will take the tired doc and his/her team over nothing, thanks.  Oh, bring in someone else to take over?  Okay.  But who?  There is a finite number of doctors in the world, and far more patients than physicians.  So unless someone has a trick to keep people from getting sick and needing a doctor in the first place, we are going to continue to have a huge demand on each physician's time.  It is unavoidable.

Then there is the problem of hand-off.  Many programs have instituted a "night float" system to avoid crossing that 80 hour/week rule.  This means that from 6 pm to 6 am you have an intern who comes in just to cover your patients over night.  It is great, since it means you get to go home (unless there is an emergent surgery).  But it creates a whole different set of problems.  Suddenly you have someone taking care of your 15-20 patients, along with the 15-20 patients of 3-4 other teams.  One intern, 70 patients.  There is simply no way he/she can remember all of them.  Mistakes are going to be made as they confuse one patient with another, as they are busy taking care of the patient who took a turn for the worse in room 2002 while the patient in 2020 needs something.  In fact, I would propose that the number of mistakes made due to this sort of hand-off is just as many, if not more, than if you had each team's own residents taking overnight call and making decisions while tired.

So what is the solution?  If someone has ideas, I would love to hear them.  But as it is, I think the system is doing a pretty darn fine job of balancing resources (# of MDs), need for experiential learning, and patient safety.  Nope, the system isn't perfect.  It has its flaws, and sadly sometimes those flaws can be fatal.  However, like it or not, mistakes are part of medicine (that is another blog), and I support the current system as it strives to care for patients while adequately training physicians.