I recently read that the prestigious surgery training program at Massachusetts General Hospital is in danger or losing its accreditation. It’s not because it has failed to properly train surgeons, or because of mistakes. The program may lose its accreditation because the trainees, also known as interns and residents, have worked more than the maximum of 80 hours per week. The hospital seems to have clearly violated the rule, but I find myself strangely ambivalent about both the rule and the punishment.
My ambivalence is rather surprising because I suffered under a program that had no limits on hours. As an OB-GYN in training, I spent five months on the surgical service during my internship year. I routinely worked about 105 hours per week, and I was awake for all 105 of those hours. The schedule required each intern to be on call every 3rd night. Therefore, the schedule was arrive at the hospital at 5 AM on the first day, work all day, then through the night on call, meet the rest of the team at 5 AM the next morning and work another full day until 7 PM (38 hours straight). The I would go home to sleep and return at 5 AM the next day and work until about 7 PM (14 hours). The 3rd day was another 14 hour day, and then the cycle would start again.
You don’t know what tired is until you have repeatedly worked shifts of 38 hours. Surprisingly, the long hours results in very few, if any, mistakes, but it turned idealistic medical students into jaded, impatient doctors. And it resulted in some very bizarre episodes. On more than one occasion I fell asleep standing up while holding retractors during surgery. It didn’t matter that much since my job was simply to stand there, but it did result in me getting chastised. One night while checking lab results on the computer, I fell asleep on the keyboard and woke with the imprint of the keys on the side of my face.
My most notable transgression while sleep deprived, though, was when I began hallucinating during surgery when I was one of the surgeons. It was a relatively minor case, and my role was simply to assist, but I kept forgetting where I was and talking to people who were not there. This resulted in gales of laughter from everyone else in the operating room. When the case was finished I was allowed to go home early (5 PM) since I clearly could not be trusted to care for patients.
The system was brutal in the extreme … and yet. And yet it taught me to be a doctor, to take complete responsibility for someone else’s life, and to never give up, no matter how long it took, until the best possible result was achieved. It was drilled into me that the patient came first; my comfort: my hunger, my tiredness was meaningless. All that counted was what the patient needed.
Looking back, I still think that 105 hours per week was too many, but I am honestly not sure if 80 hours a week is enough. At 80 hours per week, the interns and residents are essentially doing shift work, going off regardless of whether the patient is doing well or poorly. It also allows interns and residents to kick the can down the road, to slough of what should be done for the patient today, figuring that the next person can do it tonight. Finally, it is not clear that 80 hours per week allows enough exposure to different patients, different surgeries and differing ways that patients manifest illness and get well.
The surgery program at Massachusetts General Hospital has violated the rules, and if the rules mean anything, the hospital must be reprimanded and possibly punished. The real question, though, is whether 80 hours work weeks lead to better doctors and better patient care, or simply fewer hours.