Sleep-deprived Physicians: Good for Training, Bad for Patients

One of the newest partners in my medical practice laments how many hours he has to put in to build his practice. Sometimes he must even work until 8 p.m. or 9 p.m., even if he is not on call. I am sorry, but he won’t get any sympathy from me. I recall the days - now too many years ago - of building my now 12-man cardiology group. I was in practice by myself for three years before my first associate joined me. I had cross coverage from another cardiologist on some weekends, but that meant only four days off every month. Meanwhile, I had to make time to interview dozens of candidates and their spouses, including wining and dining, while still taking call and carrying a full office and hospital consulting schedule. It was not unusual for me to complete rounds at midnight, then being so exhausted I just fell into bed.

Make no mistake, however, about these days of the “iron men.” I believe this type of work schedule was, and still is, extremely unhealthy for a doctor, his family, and potentially dangerous to his or her patients. I do agree that a more humane training schedule for medical students, interns, and residents was long overdue. But as the saying goes, “the devil is in the details.” Newer physicians simply won’t tolerate what we had to put up with our training. As a fourth-year medical student at a large county hospital in Cleveland, I recall working up 14 admissions in one night and being ready to present the cases to the chief medical resident and attending by 7 a.m. Had I not taken some histories while I was examining the patient, I would never have been ready at “morning report.” I would have been “toast.”

Medicine is moving inexorably to “shift work.” ER docs have always done this, and now hospitalists have done the same. In the future, more and more specialties will follow similarly as reimbursements decline, and the corporatization of medicine grows. On balance, I think that this is a good thing. If I have a heart attack at 3 a.m., I would take a rested cardiologist, over one who just finished working a 14-hour day, without equivocation.

If I sound conflicted, it is because I am. I think wistfully of my days off “24 on/24 off” ER rotation during my internship at the University of San Diego in 1975. As I drove home in my yellow VW beetle on Interstate 5, I had to keep the windows down and play “Hotel California” by the Eagles or Jethro Tull at full volume, just to keep from nodding off. Later, my wife would plead with me to “please stay awake.”

These are bittersweet memories. Just as a prisoner-of-war comes to identify with his captors, we too reflect with some admiration at our tormentors. There was the chief surgical resident who said, “The only problem with taking call every other night is that you miss half the cases.” Another resident told the interns that if they enjoyed their sleep, then they should go into something like pathology or dermatology. Unfortunately I enjoyed cardiology too much.

Thinking back, I would likely make the same choices. Yet I can’t help but feel that today’s crop of docs are too soft, and expect too much money for too little work, I also think that their families and patients will reap the benefits as much as they will. And in the end, that’s not a bad thing.

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