A Fatally Flawed Medical Educational Model

This week, many news outlets reported on how residents should be given 5 hours of sleep after working 16 hours straight.

Think about that for a moment.

In what other job — any job in the world — would it be acceptable to even use the term “after working 16 hours.” The 16 hour workday went out with the Industrial era here in the U.S. (Residents can actually be required to be on-call for up to 30 hours at a time on a single shift, which is even more absurd.)

What other job in the world would we entrust the world’s most precious, irreplaceable resource — people — to professionals who are fatigued, worked-to-death, and under incredible stress with no hint of any kind of normal social or family life?

And yet, that is exactly how today’s medical educational model is setup. Doctors, in order to become doctors, must go through a residency period where they are literally worked until they can work no longer. Old adherents to this model suggest (with absolutely no research support) that it helps train doctors to work under pressure that the job requires. They also explain to us that it’s the only way we can afford to educate and train doctors (since anything else would require normal working hours and more doctors for coverage).

But few doctors go into an E.R. setting after residency, where such critical, immediate thinking skills would be most used and invaluable. And as for the economics of the model, well, that’s the same excuse industrialists used to explain why they needed to employ children to work in their factories in the late 1800s. And why few workers were paid a living wage (outside of the company housing).

We banned such barbaric practices back then recognizing that for a society to function and thrive, it must protect taking advantage of its citizens by companies or organizations who don’t care about the individual.

Ostensibly, guidelines are in place to try and reduce the continuing abuse of residents. They are supposed to now work no more than 80 hours per week, but this is easily skirted by averaging time worked over an entire month (so you can work 110 hours one week, and a joyous 50 another). That’s because there’s no incentive for teaching hospitals and medical schools to start acting humanely toward their residents. Apparently it’s still okay to abuse people’s rights, as long as those people are doctors in training.

I find this medical training model appalling and inhumane, and always have. Contrast it with the model under which I was trained. In psychology, future psychologists spend a year on internship, which have normal working hours (40 per week). We learn just fine. We treat people who have no money in community mental health centers. And we do significant outreach with whatever local resources are available. We have a normal family life, with many of my colleagues starting their family on internship or fellowship (an optional training year or two after internship). We hone our clinical skills while on internship, and we do so in an environment that is actually conducive to learning.

Each year, somewhere between 50,000 and 90,000 people die to preventable medical errors in hospitals. How many of those are at the hands of tired, overworked residents who can’t see straight, much less think straight?

Residents need to take a stand for humane working conditions. Working 30 hours straight is unheard of for nearly every other profession in this country (with a few rare exceptions). It is unacceptable in a civilized society, and a flawed model from its original design. A doctor can be just as well-trained working normal hours (40 to 50 per week), and likely learn a lot more if they were under less stress and pressure from their work environment.


Posted in: general | policy issues | reforming hc





8 Responses to “A Fatally Flawed Medical Educational Model”

  1. Not only are all those hours without sleep bad for residents’ health (physical and mental), but they also put the rest of us at risk when we must be patients. John, you’re exactly right that this is driven by bottom-line considerations as well as tradition.

  2. Dan Hoch says:

    What is up with our blog these days? Twice in the same day I’m going to take a position contrary to a post with which I basically agree. Yes, sleep deprived people make mistakes, and medical errors are deadly. I also agree that the culture is the problem, but I have a very different view of what causes that culture.

    First, lot’s of people work 16 or more hours a day. Junior partners in law and consulting firms, small business owners, and even the reviled corporate executive or hedge fund manager. They work these hours willingly and for profit. This is also the case with resident physicians. No, they don’t make huge amounts of money, but they do stay on for reasons of self interest, often to take part in a conference, in the misbegotten belief that the patient needs continuity of care, to work on a research project/go back to the lab, or simply for the camaraderie. I have sometimes had to tell a resident to go home after 16 hours in the hospital. But did he/she sleep?

    We can’t mandate sleep. The resident who leaves the hospital to go home and work on a grant, read, or even spend some quality time with her family is still going to come back to the hospital tired and make mistakes. It is the culture that does not reflect on the systemic cause for mistakes that is to blame, not the individuals who become inattentive, sleep deprived or otherwise impaired.

  3. John Grohol says:

    The difference between the professions you cite and residency is that residency is required as a part of the training process for a physician. There are many law opportunities that don’t require working 16 hours a day. And working hard to move up the corporate ladder (or to start or have your own business) is very different than the equivalent of a mandated apprenticeship where there really is no other choice.

    The other point is that dealing with human lives is more valuable than practically any other profession I can think of. Literally, it can be a matter of life and death in terms of making a poor decision or a bad judgment. Shouldn’t we be expecting/demanding that the people who are making these judgments and decisions be at the top of their mental game? How can anyone who’s near the end of a 16 hour (or 30 hour) straight shift with an hour or two of sleep (maybe) be expected to fulfill these superhuman qualities?

  4. Dan Hoch says:

    I agree that there are significant differences between the jobs I mention and the apprenticeship that is a residency. Point taken, and I also admit that I’ve always written it off to a cost calculation by teaching hospitals. I’m not defending the system at all. My point is that even if we mandate that residents in training can’t work more than 12 hours or even 8 hours at a stretch, the culture remains. Many will still work on other projects and career activities instead of refreshing themselves.

    Hmmm, maybe this point needs it’s own post with a title like “Why do doctors choose to become doctors?” I guess it would be nice to have some data to talk about though, not just my observations.

  5. Christine Gray says:

    There is something fatally flawed about our medical culture. While many of the above points make logical sense, it is nonsensical to “train” folks by overworking them in a profession like medicine. It virtually guarantees that they will kill a patient through a fatigue error. They thus become wedded to the profession in a way that is probably not very healthy.

    We have “normalized” this situation by artificial scarcity in medical schools. In other cultures, physicians (many of whom are women) are not so highly regarded. A doctor is a doctor is a doctor.

    At least some portion of the rigors of American medical school are culturally manufactured, resembling a fraternity hazing more than professional development. Some of the less worthy cultural notions (and the notion of the Doctor’s Wife) probably spring directly from the Greek system, if not East Coast private school traditions.

    The profession has a bad 19th century hangover.

  6. Berci Mesko says:

    We try to work on a new model at the Medical Education Evolution community: http://medschoolevolution.ning.com/

    Comments are welcome!

  7. balthus dors says:

    To John Grohol
    From Concerned Mental Health Worker
    I think you should look into the scandal concerning fees for reprinting DSM-IV-TR Tables. APA refuses permissions unless exorbitant fees are charged If you write a paper/book you are charged up to $200 per table; members are charged nothing. The World Health Organization charges nothing for ICD tables. I know of one case where and author was charged over $5000 for a chapter in a book. He could not afford it and did not use the tables. Is this academic freedom? Psychologists and social workers have little or no input into the DSM; they must pay also. DSM makes over 12 milliion dollars per printing for the APA. Please look into this. One lone voice, such as mine, is not enough, and I fear academic reprisal if I speak out. Help please. Signed A Mental Health Worker and Academic

  8. balthus dors says:

    please notify

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