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It’s not surprising that newly minted doctors at one of the most prestigious hospitals in the country, and in a specialty with a particularly demanding residency, have been violating national limits on work hours.

But the Boston Globe’s report that Massachusetts General Hospital must rein in surgical residents’ hours is a reminder that the work limits put in place several years ago remain unpopular with many residents and senior doctors.

Not surprising in the least.  I’m actually astonished that there’s anybody with the chutzpah to defend extended work hours for residents.   I did my residency largely in the pre-hour-restriction era — there were hour restrictions on months in the ER, but effectively none for the off-service rotations — and it was a terrible way to deliver care.  I did my time of q3 call in the units and q2 call on surgical services.  This includes a memorable time when I was the sole intern on the pediatric surgical service and was on duty for ten days straight without leaving the hospital.  That gives a new meaning to being a “resident physician!”  (Actually, that’s the original meaning, if you must get picky about it.)

The care provided was just scary.  I prided myself on being a machine and able to get through 36 hours of uninterrupted work without cracking; I used to run marathons and endurance was my forte.  And I did get through it better than most.  But after 24 hours with no down time (and there was never meaningful down time), you get stupid, and you make mistakes.  I remember once, in the medical ICU I was surprised in morning rounds to find that one of my patients had had a swann-ganz catheter placed overnight.  Caught flat-footed by this in front of the attending, I asked the nurse who had put in a swann without telling me, only to be informed that I had done the procedure! Apparently I was too sleep-addled to recall that I had done it!  Fortunately, I had apparently done it right, because a swann involves threading a catheter through the heart into the pulmonary vessels and can be Very Bad [tm] if you screw it up.   But I apparently did it by reflex without actually achieving a state of full wakefulness.  This sort of thing was fairly routine, and I also remember well the overnight residents being excoriated in morning rounds for the errors and misjudgments they had made overnight.  Great training, but not so great for the patients who were the victims of the mistakes.

It seems to me that the defenders of the status quo have donned their rose-colored glasses.  They fondly remember the camaraderie and the pride in accomplishment that their residencies evoked, while conveniently forgetting the mistakes and omissions, while neglecting the depression and divorces and other personal costs of such an abusive training environment.  And there’s the faux toughness: “I got through it, they can, too if they’re not too weak.”  And the old guard romanticize the qualities of the “true physician” in their dedication to their patients above all else: “These younger doctors just don’t care enough.”

What a load of crap.

Look, it’s with damn good cause that other professions in which errors can hurt people have work time restrictions (truck drivers, airline pilots, etc), and it’s stupid and arrogant to think that we physicians are so awesome that we are immune to the human factors of fatigue and circadian rhythms that contribute to errors.  When it’s inexperienced trainees working the ridiculous hours with minimal supervision (in many cases), the potential for fatigue-related errors is compounded.

I also question the motivations of some of those who defend the status quo.  It seems strangely self-serving that residency directors who would otherwise have to find attending physicians or PAs to perform the work that residents do on the government’s dime are the ones to insist that the situation is just fine, or that “the evidence of benefit is lacking.”  How cool is it that they can ignore reams of research on human factors, take the a priori position that the system is fine as it is, and demand formal evidence on “efficacy, safety and cost” before making any changes?  That’s balls!  It’s also fairly blatant obstructionism and should not be given any credence.

Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed.   Flexibility is fine, but accountability should also be demanded.

I would also take issue with Dr Bob’s comment that this “training system that has served our profession well for many years.”  I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide.  They are terribly concerning.  I would not lay all of this at the feet of residency, but I would say that the abusive (I’m sorry, “rigorous”) environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients.  Nobody is well-served by the current system.

It is true that change might be painful.  Reducing hours might mean reducing patient contacts and reducing the training opportunities for physicians.  This might require academic centers to revalue the time of physicians in training, by which I mean that residents might no longer be used as free menial laborers.  Maybe it doesn’t make sense to have a surgical resident “running the book” — many surgical residents never see the inside of the OR till their second and third years.  The universities might have to hire PAs or NPs for the “scut work” instead of using MDs in training as glorified secretaries (what a waste of time and money).

I’m glad the Institue of Medicine and the ACGME seem to be on the right path with the recommendations.  The reactionary response from the change-resistant academic centers will take some time and political will to overcome. I remember when they first imposed the rules, they followed it up by decertifying the Internal Medicine program at Hopkins for violating the rules.  That effected the desired change, I can tell you!   Hopefully, as the restrictions evolve, there will be accountability and enforcement until the culture starts to shift.

This wasn’t Gawande’s point at all, and is something quite tangential to Klein’s point:

The reason most Americans hate insurers is because they say “no” to things. “No” to insurance coverage, “no” to a test, “no” to a treatment.   But whatever the problems with saying “no,” what makes our health-care system costly is all the times when we say “yes.” And insurers are virtually never the ones behind a “yes.” They don’t prescribe you treatments. They don’t push you towards MRIs or angioplasties. Doctors are behind those questions, and if you want a cheaper health-care system, you’re going to have to focus on their behavior.

Yes, doctors are a driver — one of many — in the exponentially increasing cost of health care.  Utilization is uneven, not linked to quality or outcomes in many cases, and may often be driven by physicians’ personal economic interests.  All of this is not news, though certainly Atul Gawande wove it together masterfully in his recent New Yorker article.  (I’m assuming you’ve all read it — If not, then stop reading this drivel and go read it immediately.) Nobody disputes that doctors’ behavior (and ideally their reimbursement formula) need to change if effective cost control will be brought to bear on the system.

But it’s completely off-base to claim that insurers aren’t one of the problems in the current system.  There are two crises unfolding in American health care — a fiscal crisis and an access crisis.  I would argue that insurers are less significant as a driver of cost than they are as a barrier to access.  Overall, insurers have, I think, only a marginal effect on cost growth, largely due to the friction they introduce to the system — paperwork, hassles & redundancy and internal costs such as executive compensation, advertising and profits.  It would be great if this could be reduced, but it wouldn’t fix the escalation in costs, only defer the crisis for a few years until cost growth caught up to today’s level.  In the wonk parlance, it wouldn’t “bend the cost curve,” just step it down a bit.

But as for access to care, insurers are the biggest problem.  It’s not their “fault” per se in that they are simply rational actors in the system as it’s currently designed.  Denying care, rescinding policies, aggressive underwriting and cost-shifting are the logical responses of profit-making organizations to the market and its regulatory structure. Fixing this broken insurance system will not contain costs, but it will begin to address the human cost of the 47 million people whose only access to health care is to come to see me in the ER.