The ICU was dark, as it is at 4 in the morning. Despite a high fever, I felt that I had to come in. As the cardiology fellow shared her assessment, I told her I had to throw up. She giggled and kept right on talking, trapping me next to a wall. So sad, for her shoes were so shiny and new.
Surgeons train hard. So what? Lots of people train hard. For membership in the Consorzio Produttori Aceto Balsamico Tradizionale, you have to trek to Reggio Emilia, apprentice to a master, traipse on trebbiano, donate your left testicle to research, and wait until you're practically dead.
Considering that most of us eat condiments way more often than we have organs removed, we talk a lot about surgery. But what we talk about often isn't real. The libidinous, freshly washed princes of House are in reality unshaven, out-of-shape beasts scavenging wayward Melba toast and pestering the nurse to make coffee. Real trainees may be intelligent, but they are often tired and hungry and sick. What if a real trainee is tending to you?
Training methods scaled the peaks of national consciousness in 1984, when a young woman named Libby Zion died after hospital admission for abdominal pain. The headlines caused a swirling controversy that ripples today. At its core is the question of patient safety as a function of physician fatigue. Most specifically, her death eventually led the Accreditation Council for Graduate Medical Education (ACGME), which oversees residency training, to limit resident work weeks to a skimpy 80 hours.
The theory was that less work would mean more rest, which would mean fewer errors. Opponents claimed that fewer hours would also mean less training, less continuity of care, and a subtle transition to a dangerous corrosion of professional motivation: If my ego depends upon my patient doing well, why would I invest in a patient who is ours, let alone yours?
Has the 80-hour work week mattered? Let's look at trauma patients who, contrasted with psoriasis patients, tend to have more obvious outcomes. Well, in one study, death rates changed from 4.6% to 4.5% in the periods before and after imposition of the 80-hour work week.
There are other examples illustrating that while - news flash - trainee attitude worsens with sleep deprivation, patient outcomes essentially do not change. Obviously, there is a limit to just how little sleep surgeons can get and still train well and perform well. And it matters who is being sleep deprived: The judgment and skills of senior surgeons is affected less by sleep deprivation that those of trainees. But the devil is in the details and the quantitative optimum has apparently not been established by the ACGME.
So do trainees limit themselves? Do they back out of work when circumstances are less than ideal? Not necessarily. Nearly 60% of residents answered affirmatively when asked: "Were there occasions that you think you should have taken time off for illness, but did not do so?" Like the backhoe operator who is coughing up blood but keeps digging, trainees often finish the job. Again, the devil is in the details: You may not want to have a resident in labor do your spinal tap.
Because illness happens also at nights and on weekends, a culture of service - a reflection of professional pride - is vital to patient welfare. You cannot legislate it in but you can extinguish it with bad legislation. The challenge to legislators is to restrain themselves.
The challenge to the profession is to construct a process by which young surgeons can gain experience without killing their patients. At its heart, the process will mix pride with rigor and supervision.
The challenge to the patient is to find a surgeon who has lots of experience. And commitment to show up when it's needed.