Monday, June 27, 2011

Duty Hours Pre-Form Part 1: Can you even do that?

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When I was an intern I was once on a rotation where we took call every third night. While it wasn't as bad as the "24 on/24 off" schedule that the Surgery residents did--it was still pretty sucky.

So yeah. One in three. That meant that on any given day you were either on call, post call, or post-post call (which everyone knows is twenty times worse than being post call.) Anyways. For those still confused, it meant that every single weekend you were guaranteed a crappy schedule.

Friday: On Call
Saturday: Post Call
Sunday: Exhausted and dreading on call.

Your weekdays were equally crappy:

Monday: On call
Tuesday: Post call and staying around because there's only two other interns.
Wednesday: Post-post call and stuck with all the work because you're the one nobody feels sorry for.

That's pretty much how it worked. This was also before anyone gave a hoot about duty hours or sweatshop working conditions which meant that this little schedule was even more heinous than it sounds. Let's examine the old school, pre-ACGME Duty Hour Rules era call schedule a wee bit closer, shall we?

The dreaded post call in clinic schedule:

Wednesday: On call and with out a single drop of sleep all night.
Thursday: Post Call
Thursday morning: Post call morning report in front of the whole department.
Thursday later in the morning: Getting grilled on rounds with more questions as if the ones you got on morning report weren't enough.
Thursday at noon: Sitting in noon conference while writing progress notes because you have to be at noon conference yet you have clinic at one p.m. and need to get them done.
Thursday at 1 PM: If this were today, you'd be starting your car. But back then, you bought a cup of coffee, jumped into a call room to change clothes, and then sprinted to clinic.
Thursday 3PM: Asking patients the same questions over and over and over. Because you are sick with exhaustion.
Thursday 4PM: A bizarre second wind comes over you. Seeing patients, answering pages, kicking ass and taking names. Who's better than you? Answer: Nobody.
Thursday 5PM: Running from clinic back to the UNIT to join the sign out rounds. YES. I said "Go back to the unit." At 5PM. Post call.
Thursday 5:30: Leaving the unit because you "got to go first since you're post."
Thursday 6PM: Fall asleep at every single stop sign on the way home.
Thursday 6:20PM: Eat two poptarts. Fall asleep with all of your clothes on. On the couch.
Thursday 7:30 PM: Classmate calls and asks, "What's up!?"
Thursday 8:00PM: Jump in the shower to get ready to meet your classmates because you know that this is the only chance to do anything fun and this is your "Friday."
Friday 5:30 AM: Staring at alarm clock tearfully and fearfully.
Friday all day: Walking around like a zombie and getting worked to death because you are the only one who isn't "on call" or "post call" -- which is why that day always sucked.

So here is what's extra crazy. That month with that schedule, my co-resident and I decided that we each wanted two consecutive days off. So like the sleep-deprived idiots that we were, we made this executive decision to each take two calls in a row. Yes. In a row. Oh, and did we ask anybody's permission to do this? Uhhhh, of course not. That would be too much like right.

So check it. That was the plan. I take call on Friday-Saturday, my classmate would do Saturday-Sunday the next week. Stupid as hell! I know! Anyways. I come in with my bag on a Friday go through my heinous work day and then admit all night. And that night? Oh it was a rough one. No sleep whatsoever. So Saturday morning I'm sitting at the nurses' station with my head down on my folded elbow likely in a pool of disgusting slobber. Then I hear my attending's voice:

"Rough night, Kim?"

I popped up and looked at him with blood shot eyes. "Uuuuhhh, huh?"

"How many did you get?"

"Many what? What patients? Uuuhhh, I think we got like. . ." I pulled out my cards and started counting, "uuuhhh, like six people. They were okay. Well, one was kind of. . .uuuhhh. . .no, it was fine."

The attending narrowed his eyes and looked at me like I was a little off. This guy was just covering for the weekend so didn't really know me so well. If he had known me well, he would have known that I was off because not only was I nauseatingly tired but simultaneously stupid enough to be admitting for the next twenty four hours. Again.

"So, you're post call obviously," he said. I'm still not so sure I appreciated that little "obviously" dig. Then he looked around the unit and asked the dreaded question. "Where's the on call intern? It's 7:30 and I'm ready to rock and roll."

I wanted to splash my face with water or something to convince him that I wasn't as dangerous as I looked. No time for that. "Uhhh. . .yeah. . . the funny thing about that. . .yeah. . .well, I'm the on call intern."

He furrowed his brow and froze. "You? But you're post call."

"I know, sir. But I'm taking Kevin's call today so that we could each get some time off."

"You're taking two calls in a row? Can you even do that?"

I shrugged my shoulders and tried to smile. I wanted to give him as few words as possible. Besides--Kevin was no where near that hospital and he damn sure wasn't coming in to take call.

"Have you seen all of the patients and written notes already?"

"Yes, sir. I did." Which was true. Haggard, yes. Sloppy with work, no.

He shook his head and sighed. "Okay, then. Let's rock and roll." And that was that. No threats to call my chiefs or my program director. No screaming fit about how awful it is to put my patient's--his patients--in danger with our selfishly asinine plan. Nope. Just a head shake and a request to do what the man came to do. Rock and roll.

So that's exactly what we did. We rocked and we rolled. And then he left. And I stayed to admit seven more people that night. I did get like twenty minutes of sleep--which everyone knows is twenty times worse than getting no sleep when you're that tired.


On Sunday morning, I was in a stupor and I had altered mental status for real. I fell asleep standing up twice and wrote notes in charts that looked eerily like hieroglyphics. Not good. Not good at all.

I am pretty sure that nobody got hurt, but really? Two calls in a row--voluntarily? Really?

Okay. So today I'm reflecting on this new rule effective July 1 that prevents interns from working more than 16 hours straight. The hours can be longer for upper level residents, but first year-fresh outta med schoolers must keep it under 16. Wow. I'm so marveling at how sharply the pendulum has swung in less than fifteen years.

That two call in a row story used to be funny to me. But you know what? It's really not. It was one of the stupidest and most dangerous things I ever did in my entire residency. My friend Kevin and I told that story like old Army Rangers talking to young privates; "when WE were interns we worked for 53 hours straight!" Now that I am actually writing what we both did, it sounds even worse.

But the thing is. . . .as an intern and now, I intensely yearned to have a personal life away from work. I needed a minute, a real minute, just to be me and to breathe. And I needed some time to do it. Even if it meant working for 53 hours straight.

Isn't that terrible? Needing to risk my life and that of my patients just to have a minute to breathe? That's a damn shame.

Okay. So now it's kind of built into the rules for residents to have balanced personal lives--or at least to have time to try.

So what's the moral of this story?

It's good that things are different now. It really is.

Oh. And if you are currently an intern and you don't have a life? Blame yourself for being lame. Not temporary insanity. Or your crappy schedule.

Stay tuned for part 2: "No sleep 'til Brooklyn"-- The story about when Dr. Winawer mowed down a row of parked cars post call in Manhattan. You think I had temporary insanity? Laaaawwwwdddd. . .


  1. Yeah. I'd really love for an intern who hadn't gotten any sleep in over 24 hours to take care of me and my pain and problems. I am so glad things have changed somewhat. At least. What was the point of all of that? To drive home the doctor-as-god thing? Doctors are human, last time I checked, and as such, well...You know.
    Pilots, truck drivers, doctors- they all need enough rest to ensure that they can do the job they need to do. Safely and with good judgment.
    And mothers too! But that's a different story.

  2. I hear you on MANY levels! Yet as a freshly minted residency graduate( yay ! ) , I think that by limiting interns to a 16 hour minimum, aspects of patient care and acculturation to learning what it is to be a physician will be , well, lost. Mind you, I am perhaps biased coming from a program where we understood that the duty hours were to be broken despite reporting otherwise.

    The thing is- though you to repeat these years- there is something to be said about learning to function under extreme conditions when you are responsible for a crashing patient's life. This profession, especially surgical specialties, demands that it be so. Patients count on physicians to be able to find solutions for them during their most vulnerable moments in life- literally. There are simply, more often than not, circumstances in which " I am tired " just cannot be: while working 50 plus hours consecutively is a negative extreme, limiting interns to 16 hours is as well.

    Despite my heavy workload, I am in many ways grateful for it, as it taught me effective problem solving under duress, and allowed me to know what was going on with my patients: the whole sign out to a different team can be fraught with danger-literally. Sorry to blog in your comments! As always, love your blog!

    A Fellow Meharrian

  3. I just found your blog and it is a true treasure. I am an ob/gyn who trained at Grady, finishing ~10 years ago. I understand the rationale behind the work hour rules, but I think we are training physicians with a "shift work" mentality. As much as I hated doing q3 call during my third year, I truly feel it made me a better physician. The residents I see know seem to want to work 8-5 and "be out". Working a full weekend of call is murder for them.

    Working grueling hours with a safety net in residency gave me a depth of knowledge private practice never will.

    I may be exaggerating, but the residents coming out today scare me.

  4. I disagree that the old torturous call made us better doctors. I once worked 40 days without a day off. I am not kidding. I fell asleep while writing a note...pen sliding off the page and head collapsing forward. I thought of the patient as my enemy. I used to say if I was going to die, I would want it to happen BEFORE my next call night...not after. That would be too cruel.

    I think the suffering we did as interns and residents may lead to the "entitlement" that many physicians manifest. Surviving such a system really did make us feel special, just like hazing or any initiation.

    I think there are better ways. The new regs allow 24 hours shifts and 16 hour shifts for lst year. They allow 80 hour work weeks. Isn't that enough?
    Do we really want to perpetuate a system that might be dangerous for our patients?

  5. Fascinating post and discussion. My brother is a doctor and his memory of these brutal intern hours and lack of a social life had him seriously trying to convince my son not to go into medicine. Well, my son just switched his major to pre med so I read all this with avid interest. He is the sort that will benefit from capped hours otherwise he would just go go go, possibly beyond what was safe. I'm a lay person but it does seem to me some limit on hours makes sense.

  6. Ms. Moon- Yes! Mamas do need Duty Hours Reform! Dang--let's get on that!

    Fellow Meharrian-- I feel you. Some of my best learning took place between hours 16 and 30. A lot goes down in the middle of the night. At least upper levels will get that experience--all isn't lost!

    Anon 2-- I think fields like OB and Gen Surg are the hardest. OB really requires you to be there to see things evolve. When I got induced with my first (9 freakin'plus pound!) baby they started it the afternoon before and I delivered the following day. Anyone on a 8 - 5 schedule would have missed out on hearing me screaming bloody murder. Ha. Seriously, though. . .I have good news. There are really some wonderful graduates coming out. Really, really great ones. My opinion is that the 16 hour rule may be extreme, especially for surgical fields. Those may be the ones that require a second look at this policy.

    Dr. Toni--I know all about that pen sliding. Yeah. We do sometimes beat on our chests and holler like we earned that right. Interesting perspective. Thanks.

    Angella--Your sweet son will do well in whatever climate medicine offers when his time comes. This I know for sure. Why? Because I know for sure that he has grown up cherished and valuing life and people. See-- this? THIS is what we need in our next generation of doctors. THIS we cannot teach.

    You have taught your children this. Yes, you have. Thank you for always being such a solid example for me in the Mom-army. You are one of my Mom-Colonels. You so are. :)

  7. I don't know how y'all do it! Seems to be an extremely! hard schedule/hours. wow. I'm so thankful for you all! Why ARE the shifts so bad?? Not enough workers?


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