(Julia Fullerton-Batten/Getty Images)This week, a panel for the Institute of Medicine recommended mandatory sleep breaks and more structured shift changes for doctors-in-training. The panel focused on the grueling hours put in by medical residents, the recent medical school graduates who care for patients under the supervision of a fully-licensed physician.
While the focus was adding sleep time to 30-hour shifts as a way to curb doctor fatigue, one key point may have been missed. Many residents don’t want to nap or leave the hospital. They want to put in whatever hours are necessary to care for patients.
In her latest “Doctor and Patient” column, Dr. Pauline W. Chen talks about her own 100-plus hour workweeks during residency and the education she received in the process. She writes:
I can’t help but wonder if we may also risk losing something by trying, prematurely perhaps, to fit the unpredictability of the illness experience and the individuality of human relationships into a scheduling grid that has little proven efficacy.
To hear more from Dr. Chen, click here to read the full column, “Does More Sleep Make for Better Doctors?” And please post your comments and join the discussion below.
Healthy living doesn't happen at the doctor's office. The road to better health is paved with the small decisions we make every day. It's about the choices we make when we buy groceries, drive our cars and hang out with our kids. Join columnist Tara Parker-Pope as she sifts through medical research and expert opinions for practical advice to help readers take control of their health and live well every day. You can reach Ms. Parker-Pope at 
The easiest and most pleasurable way to eat well is to cook. Recipes for Health offers recipes with an eye towards empowering you to cook healthy meals every day. 
From 1 to 25 of 316 Comments
As a 2nd year medical student who spent the summer in the Surgical ICU at a very well respected New York City hospital, I can tell you that the residents spent way more time with non-educational tasks (ordering tests, drawing blood, transporting patients) than they did actually providing patient care.
— LVSAs I think about the life I saw them living, I can tell you I would much prefer to spend 100+ hours in the hospital with competent and fully staffed ancillary services (nursing to draw blood, techs to order tests and track down lab values, and patient transport to move patients) than to spend “80″ hours in a hospital with under staffed ancillary services.
Careful Dr. Chen. By taking this stance, you’re officially standing with the all-boy network that takes sadistic pleasure in the torture of med students, interns, and residents. This is the same network that routinely berates nurses (see the “Arrogant, Abusive, and Disruptive -and a Doctor”article). Interestingly, this article cites resident abuse and lack of sleep as justification for why the same doctors go on to later abuse nurses and other coworkers later in their career. Dr. Norcross speaks in the article, and is quoted, “the brutal training surgeons get, the long hours, being belittled and ‘pimped’ ” — a term for being bombarded with questions to the point of looking stupid. “That whole structure teaches a disruptive behavior,” he said. There is a link to the two articles, and it’s important that people realize such a link exists. Abusive hours breed abusive behavior.
Lack of sleep in residency is abuse, plain and simple. Ask any doctor who went through residency will agree that it was an abusive and horrible experience that they would NOT go through again. It is universally regarded as abusive. Every single psychological research publication comes to the same conclusion regarding abuse, and that is that those who were abused tend to abuse others. The cycle gets passed down from one generation to the next. However, simply because it happened in the past doesn’t justify it.
Written by,
— SaviSavi, second year med student (yes, a medical student, and a member of this generation!)
Another example of the “one size fits all” mentality of most clinical education. Such rules may work well for some people but not for others. The educational system will never be very good at accommodating individual differences. It could, however get a lot better at identifying stressed out physicians. For that to happen, however, a change in the environment of training would need to occur. It is the rare physician who will admit need for rest - the risk of belittlement, exclusion, being envied - seems too great. Unfortunately “Suck it up” is still the mantra in training. Traditions based on macho images die only a long, slow death, if ever. Medical students - Choose wisely!
— DS BostonI totally agree with you. The bunch of recent residents are becoming increasingly lazy and the more these regulations about time and sleep have come, they become more lazy and I find the compassion and the patient care just disappearing from these residents. I can say so because I just graduated 6 months back , but when I ask them to do tasks as an attending physician, they are looking for reasons how not to do it. like hours, number of patients etal..it was never like this in the past for sure.
— simiSeriously? Who wants a doctor who is so fatigues after working such hours? I want my doctor to be well rested. Not struggling to stay awake with a scalpel in her hand, hovering over me. This seems like a no brainer.
— JustinWhat the trainees “want” is nowhere near the top priority here. The statistics plainly state that when you cut your amount of sleep in half, your medical errors double. So you’re saying that just because a resident wants to sleep less, we should allow this?! Come on Tara, that’s laughable. What is good for the *patients* is what comes first.
— JohnI finished residency in 2006. I too have mixed feelings about the concreteness of the 80 hour work week. I remember being pressured and berated by others for NOT finishing my work on time. Some of my most memorable learning, as a physician and as a human being, came when I was most exhausted. I remember holding a dying physician’s hand at 6am, after 24 hours of non-stop work and another 10 hours ahead of me.
As painful and abusive as residency can be sometimes, it was a privilege and it was the time of my life.
— CA MDi think it is unfortunate that activities such as drawing blood are now viewed as tasks not worthy of the doctor-in-training’s time. Arrogance and nastiness are not a consequence of long hours and little sleep, but out of the sense of entitlement that comes of relegating activities such as these to “ancillary staff”. The laying on of hands is a critical part of medical training - and drawing a patient’s blood or helping a patient with simple physical tasks is as much a part of that experience as wielding a scalpel or an endoscope.
From Pauline Chen: I agree with you that learning the laying on of hands is a critical part of medical training. I do agree with the Institute of Medicine committee, however, that it may not be the best use of a resident’s limited time to have her or him chasing down misplaced lab reports or scheduling appointments.
— annaHaving gone through graduate school and roomed with two medical students, we all agreed that a large part of our training was ritual hazing. Our profs had gone through this and this was all part of paying our dues.
That said, I teach undergraduate students who are often sleep deprived (usually due to poor time management and planning). I have have fellow students nudge them as they sleep in class. I have also read papers that clearly were hastily written.
My ex was a nurse who worked the night shift. Between those shared with my by her and my med school roommates. . . well, you would all be surprised.
Research and just plain common sense tells you that people make serious mistakes when they are fatigued and sleep-deprived. Research also indicates that short naps can held refresh and increase productivity and effectiveness. Even pilots and other members of the flight crew on long haul flights are required to take a rest. There’s a reason for this.
If we don’t expect our airplane pilots to work while exhausted, why she we continued to require our medical residents to do the same?
— professor2000I have a kid who is a night person and can have a whole conversation in the morning and never know she had it. I am a morning person and whipped by 5 PM. What about accommodating the diurnal nature? I know it would make scheduling a bear.
— StarWe have a system now that strikes a balance between duty hours and rest. I just finished a 30 hour shift, and I want more sleep! But there are not enough doctors in the world to provide 24 hour coverage at every large hospital in the US if we all only worked 8 hour days as residents. And, the IOM report neglects to take into account the number of lives that are saved by fatigued residents at 2 am. WIthout them (as in most community hospitals around the country), the covering doctor isn’t in the next room over, he or she might be in the next town over. Please postpone your cardiac arrest while they drive in.
— DougI deal with this at a much lower high school level preparing students to enter college programs where half the freshmen fail out the first year. For some professions, we have make the students tough, have to make then competitive, have to make give them a personal interest and stake in their own success. Sometimes this can be seen as abusive. However, I think we also have to teach them proper habits. Many posts take about rude doctors, and this is a big issue. There is never an excuse to belittle a person, even if one can get away with it, or even if one might feel peer pressure to do it. yet sometimes we model such behavior, out of sheer habit. Lack of sleep and proper diet leads to many deaseasie, yet we ask out doctors to train mentor their students in exactly such behavior.
My question is this. If an intern can be asked to do whatever in necessary to insure success as medical practitioner, then, as someone who genuinely is interested in the answer, why can’t they be asked to take a nap. If an intern was asked to look into a patient, and that intern refused because of lack of sleep, would that refusal be acceptable?
— r coxSavi: “Ask any doctor who went through residency will agree that it was an abusive and horrible experience ”
I’m not a medical student I am a doctor and did go through that and no it was NOT abuse. It actually prepared me to deal with critically ill patients - patients who when sick do not care how many hours you work. They just need you to take care of them even if you have a dinner day at 6pm. Those of us who were trained before working hours are better prepared than future doctors who will be training without the pressure. You need to be able to think and work under PRESSURE. If you were trained to work m-f 9-5, you will be ill-prepared to deal with any stress when you finally become a doctor.
— jeffjImagine if marines were trained 9-5 and had to go home to get their beauty sleep. It would be fine until they had to go to war.
And it’s not an “old boys network”. Women go through it and handle it just as well as us guys thank you.
As a nurse who has worked double shifts (16 hours) I can tell you that you don’t want a doctor who hasn’t slept in 30 hours to be making decisions about your care.
— JanetMy husband is a senior surgical resident now. He regularly exceeds 80 hours, but it is “his responsibility” to ensure that his work hours documentation meets requirements. No one explicitly requests that he fabricate, but the implicit message is clear.
One day, after staying up all night operating, he was post call (supposed to leave by 1pm), and at about 4 in the afternoon, over an open surgical wound, his attending said, “You look tired. Feel free to leave if you need to go pick up your skirt at the dry cleaners.”
Contrary to Pauline Chen’s leisurely experience, he doesn’t spend all of his extra hours waxing poetic with his patients, performing rare surgeries, or having deep philosophical discussions with his faculty. He is conducting clinic visits with less than 10 minutes per patient, scrubbing into routine surgeries, and completing the all of the dictations and documentation that his faculty subsequently signs.
— JillThere’s so much to learn in so little time that very long hours are required. The more pertinent questions are whether the investment in time brings an adequate financial and practice satisfaction return after training. For too many physicians the answer to both is they don’t which brings to mind this joke. A doctor complains to the plumber his bill for a brief service is more than he gets for the same amount of time treating a patient. The plumber responded saying when he was a physician he couldn’t get that amount either.
— MARK KLEIN, M.D.Savi wrote:
“Lack of sleep in residency is abuse, plain and simple. Ask any doctor who went through residency will agree that it was an abusive and horrible experience that they would NOT go through again.”
This fully trained physician (who finished his training before the work-limit rules went into effect and trained at a VERY busy hospital) never felt abused. Further, I can think of no colleague who felt “abused,” yet I heard that my program was, as the saying goes “malignant.” I definitely worked 100 hour weeks, occasionally q3. Yes, there were times that I was too tired, but I was not abused. I do not think that working long hours is punishment (or hazing), I just think that working long hours is, to some degree, inevitable.
I have some problem with the work rules as they are:
1. They inevitably teach that medicine is shift work. Wrong. You may not want your Dr. to be tired, but you definitely do not want her to think she can just go home if you get real sick at an incovenient time. By the way, what do you think happens out in practice?
2. They are utterly unimaginative in their approach to the fact that handoffs are dangerous. A tired Dr who knows your case will likely take better care of you than the chipper one who knows your case from a 3×5 card and did not know how you were doing 2, 4 or 12 hours earlier. I found that 1-2 hours of sleep at a slow point in the shift (if there was one) made the next day doable. Not easy, but doable. I would favor trying to create a cross-cover system that enforced a nap, but then allowed the MD to return to work. Folks, there is SO MUCH that needs to be done on the day after admission. This work should be done by the admitting MD. In any event, my hypothesis that a nap could minimize errors is testable . . .
Just thoughts. I agree we need something to keep hours decent, but we need more innovative (and practical) solutions.
— Ronaldregards,
I don’t particularly care what the doctors want. All I know is that when I get in a car accident and go the hospital, I have no say in who treats me. It could be the intern who’s had sleep. It could be the intern who is too macho for sleep. What choice do I have? None. Why should the doctors have any choice, then?
— JenI don’t care what the doctors want. I care about making it our from under their hands alive. Botch my procedure so that you can show that your just as “tough” as your collegues? That’s called “dumb”. No thanks.
— Kathy KrikorianReading Dr. Chen’s article, it’s all “I…I…I”. This gives good insight into why the medical establishment supports practices that endanger patients. The residents may learn faster, the hospitals get cheap help, but patients suffer. Our malpractice system is so broken patients that suffer error are rarely compensated, if they can even find out about the error.
— ALI don’t buy this argument. I went through a PhD program that required 80-100 hour weeks for the first couple of years. I did learn some things, but I spent a lot of time doing less-than-perfect work because I was exhausted and didn’t have the strength to care anymore. So I worked long hours, but I believe that if I worked less, I would have learned the same amount, because many of those hours were spent “asleep with my eyes open”
Also, the first people who suffered were the students whom I had to teach as part of the program, because a person who is exhausted and on edge is simply not going to be empathetic and helpful. Frankly, I’d rather not have a doctor who has been on duty for more than 24 hours doing anything to me.
— MaryI work 80 hours a week on a busy ob/gyn service as a 3rd year resident. Maybe it’s because my private hospital in a different state has non-unionized nursing - but I am not faced with a lot of scut when I’m on most services (gyn/onc being the only exception). In med school, in nyc, where the union dictates everything, I found the nursing staff and the support staff to be generally unhelpful to the residents, unless they asserted themselves. They would almost always ask nicely the first time - but after that, what can you expect? I’m so sick of reading about how awful we residents are - and even more annoyed by the condescending nature of the current crop of med students - just wait until they get into residency and learn to get a life. (I’m sure most of the biggest complainers will try for surgical sub-specialties as well.) Just quit medicine if it’s so bad - believe me - we don’t want people like that in my residency program, where we all actually get along, live with the lack of sleep and long hours, have to take occasional nasty 2 am push-back from a very good attending with 20+ years of experience, and learn a hell of a lot.
I wish these disgruntled people would just stop talking and start observing, listening and learning that medicine is HARD and no one is going to hold your hand. I sure would not want a doctor who had been spoon-fed every single bit of their training just so that they “felt better” about themselves. But I guess this blog would have far fewer respondents if the authors tried to point out the non-negative aspects of medicine and medical training today.
— Gal DocRe Doug: “WIthout them (as in most community hospitals around the country), the covering doctor isn’t in the next room over, he or she might be in the next town over. Please postpone your cardiac arrest while they drive in.”
The fact that the MD isn’t in the hospital anyway is a good rationale for home births. If you call the MD when you’re heading out to the hospital ’cause something isn’t going right, you won’t get there any earlier than the doc anyway.
— HardyWYup- the “MDeity”,macho -don’t admit weakness- and at it’s very worst -martyrdom personality culture STILL exists in contemporary US Medical training and practice.
It is immature and patently dangerous.
We need to grow up in this profession
We are humans trying to help other humans. Fatigued physician who believe they must be martyrs to be effective in this profession are harming themselves, their families and certainly their patients
— Dr. Rick LippinAs a 4th year medical student at a well regarded Boston insitution, I’ve worked side-by-side with interns and residents, keeping their same hours. Rarely do any keep to the 88-hour work week (80+near-standard 8 hour exemption). In one case, an intern who honesty logged the 110 hours/week he worked on a previous rotation was told by the chairman of that service to “correct” his previous month’s log to conform with the work hour restriction, which the chairman takes “very seriously.”
When the expectation is that a resident works 100+ hours per week, asking if they “want” will not give an honest response. The truthful answer is a definitive yes. The answer expected is a resounding NO for fear of appearing weak or lazy.
— HMS