30-hour day

I have not written much lately.  I have not done much of anything except work.

As part of my emergency medicine residency, I am required to complete two months of training at the University of Maryland Shock Trauma Center in Baltimore.  I enjoy being back in the city of my graduate school days, but the schedule at Shock is absurd: 80+ hours per week and call shifts in which I remain awake at the hospital–making critical life or death decisions about patient care–for 30 hours straight.  It is brutal.  It is unhealthy for residents.  It is unsafe for patients.  Yet, the culture is one of “It has always been this way.”  That doesn’t mean it should stay this way.

I tell every patient, and am now telling you, that I have often been awake for more than 24 hours when I am trying to figure out how to save a person’s life.  My brain is so tired, I frequently have trouble speaking clearly.  Patients are universally, and justifiably, appalled by this information.  I hope the reader need not require hospitalization, but if you do, ask your doctor for how long she or he has been working on shift.  The answer may not be a comforting one.

Upwards of 250,000 Americans die every year from medical errors.  The medieval, ridiculous, dangerous culture surrounding physician work hours surely is a part of the problem.  Physicians apparently refuse to heal themselves, so it’s up to readers and patients to demand change, to demand well-rested doctors, and to demand oversight and penalties for renegade providers and institutions that push physicians beyond all reason and margins of safety.

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Medical School: the cast

MED STUDENT

Generally considered a semi-sentient creature ranking just below newts and precocious fungi on the evolutionary tree, the medical student is able to process crude emotions and to withdraw from painful stimuli, but has rarely been observed performing higher-level cognitive functions.  Masochistic at best, and likely suffering from pathological psychosis, the med student chooses to undergo four years of studying 100+ hours per week while suffering routine ridicule from clinical instructors who treat him or her with approximately the same level of respect as one treats the sock lint that accumulates at the tips of one’s shoes.  Med students are easily recognizable by their shuffling, dejected gait; by the patronizingly short, white coats they wear; and by the ease with which they create awkward situations, such as turning red-faced and stuttering during the clinical breast exam or gleefully offering to manually disimpact a 90-year-old constipated elderly man.  Being unlicensed, the med student cannot provide any substantive assistance to the medical team but does serve as a convenient scapegoat for any failings of the US medical system–whether medication errors, missing documentation, rising healthcare costs, the collapse of Medicare, or unpalatable cafeteria food.  In a process that still baffles leading scientists and that should terrify the general public, the med student on the July 1st following his or her graduation from medical school ceases to be a lowly bottom feeder and metamorphoses into a resident physician who is expected to knowledgeably manage patients.


RESIDENT

The resident.  A med student in heart; a doctor in theory; a peon in reality.  Residents are the curious hybrids of the clinical world.  They have graduated from medical school and, having earned a medical degree, enjoy the esteemed title of “Doctor,” without any of the privileges: they cannot yet practice medicine independently, they don’t have vacation homes in Monaco, and they don’t drive vintage German automobiles.  Instead, they labor at the hospital under the auspices of attending physicians (see below) in a sort of medieval apprenticeship called “residency,” in which they obtain further medical training in a specific specialty such as emergency medicine or dermatology or orthopedics.  The length of this purgatorial residency varies from three years for primary care fields such as pediatrics to seven years for surgical disciplines such as neurosurgery.  The cushy schedule during residency involves a mere 80-100 hours of work per week.  The resident typically arrives at the hospital at the hearty hour of 3 or 4 AM, visits all of the patients on his or her attending’s list, and then writes notes and places orders for each patient–knowing that the well-rested attending will arrive after a morning tennis match around 11 AM and will berate the resident’s medical decisions while issuing directives that exactly match the resident’s original orders.  The resident then remains at the hospital until 8 or 9 PM to complete the day’s activities and to polish the attending’s golf clubs for tomorrow’s early morning tee time.  Residents are easily spotted as the sleep-deprived zombies in wrinkled scrubs and dingy white lab coats running frenetically around the hospital and answering a constant stream of ringing pagers strapped to their waists.  Raking in an average gross salary of ~$50000, they enjoy a competitive hourly wage of just over $10/hr, an ample return on their investment of 8+ years of higher education and only slightly less than they could make stocking shelves at the local department store or selling their nonvital organs on Craigslist.

 


ATTENDING

The word “attending” operates in everyday speech largely as a participle or gerund (e.g., “Attending church was a Sunday morning tradition…”), but in medicine, it serves as a noun for the doctor in charge of the medical team caring for a patient.  It translates roughly as “Boss Man,” “Divine Being,” or “Your Majesty.”  Technically, the word is only the first half of the phrase “attending physician,” but the full title is rarely necessary; the mere utterance of “attending” generates immediate genuflection–if not prostration–on the parts of all sentient beings in the vicinity.  Having usually studied alongside, and perhaps even tutored, lesser healers such as Hippocrates and Jesus, the attending possesses unassailable authority.  He or she dictates the diagnosis and therapy for each patient under the team’s care and makes certain to criticize, refute, and ridicule any and all aspects of the team’s clinical decision-making.  It is customary for God to seek the attending’s permission prior to intervening in the outcome of any given patient.  For mortal humans, receipt of no fewer than twenty-six Nobel prizes is required before one may speak directly to an attending.  Residents and medical students must not meet the attending’s gaze, and students in particular must take caution not to step within the attending’s shadow, lest they risk immediate corporeal combustion for transgressing the sanctified boundaries of Holiness.  Attendings earn prodigious salaries, take solemn oaths to drive only Porsche and Audi vehicles, and live in resplendent luxury while their resident underlings work 12x harder than they do but can scarcely afford the crumbs of the imported French brioche that the attending has for breakfast every morning.  Lastly, attendings do not die; they answer Death’s page, at their own leisure.