Slate has a column on the downsides of efforts to force residencies to allow residents to get more sleep:
In Europe, where thousands of physicians were needed to fill vacancies created after residents scaled back their hours, hiring additional personnel cost an estimated 1.75 billion Euros. Exceeding the 48-hour-a-week allotment “is the rule rather than the exception” in Portugal, noted researchers in a 2004 British Medical Journal article. The United Kingdom needed an estimated 15,000 additional doctors to staff the National Health Service to comply with the Working Time Directive, which applied to junior doctors for the first time in 2000. In 2004, the BBC reported that the NHS was facing a “staffing crisis” brought on by shorter hours for residents.
But too few doctors isn’t the worst of the consequences. Proficiency in the operating room notoriously demands long hours, and one-third of orthopedic surgical residents were deprived of training in the operating theater because of shorter work hours, according to a 2002 survey by the British Orthopedic Association. “To become a competent surgeon in one fifth of the time once needed either requires genius, intensive practice, or lower standards. We are not geniuses,” wrote the authors of an article published in the British Medical Journal in 2004. “That many senior house officers arrive at posts halfway through their rotations without any real competence in operative skills as basic as suturing and tying knots is therefore unsurprising,” they noted.
The article brings up a lot of good points. There are definitely advantages to the ramped up schedule that doctors currently undergo. I also agree that 48-hour workweek regulations like those in other countries is pretty impractical.
That being said, I have at least two problems:
First, we have got to stop treating sleep like some sort of luxury or worse yet treating the need for it as some kind of weakness. If and when they create a pill that allows people to operate without sleep, then workweeks exceeding 80 hours and shifts exceeding 30 might not be so problematic. The problem within the medical community persists with this notion that doctors are impervious to biological limitations. A lot of doctors seem to think that fatigue is something that can be trained out of somebody. Clancy said that it is the position of some in the medical community that you want would-be surgeons to have such rock-solid experience so that they’ve done it so many times that they can practically do it in their sleep.
We drive our cars every day. No one has to be reminded what to do. It’s about as second-nature as it gets. A lot of the time bad things happen when we get so comfortable doing it we stop paying attention at all. Yet almost nobody seriously argues that we should allow more experienced and active drivers the opportunity to drive drunk since they’re so skilled. Sleep deprivation is really not that different drinking in its effects on thought capacity and coordination.
So when the author of this article proposes that while some doctors should be allowed to take naps (if, you know, they must), residencies should have the flexibility to be able to let those that can work more do so. That’s like saying “Oh, so you think that you can drive drunk? By all means, here are the keys.” I honestly don’t care what the doctor thinks that they can do. Even apart from this, doctors have reputations for believing that they know a lot more than they do and believing that they have levels of competency outside their expertise that they do not have.
That brings me to the second objection, which is that any talk of allowing residencies “flexibility” so that they can “work with” residents is moot. That suggests that there is a degree of symmetry in the relationship. It displays a remarkable ignorance of what residency is like from the point of view of the resident. You do what the residency tells you to do when the residency tells you to do it. The more you work, the more bang for their buck you get. They have motivation to train future doctors, but they also have motivation to get more bang for their buck They have much, much less motivation to be even remotely concerned about the well-being of their residents. Mandatory work hours are the only protections that residents have and any and all flexibility given to residencies will become burdens on the residents.
There are maybe some things that could be done. Paying residents hourly might not be a bad idea if it gave residencies some incentives not to overwork their charges. You can also make residency take longer. Maybe offer more programs so that young people don’t have to get a full undergrad degree before going into medical school and spend the time that might otherwise be reserved for undergrad work instead in residency. Or add something after formal residency where doctors have to work in a moderately supervised environment before they can work truly independently. And, though the AMA is naturally reluctant, create more doctors.
One thing that should not be an option is pretending that sleep is for the weak.