AMA Journal of Ethics^®

Case

Mary, less than halfway through her intern year in surgery, was already feeling burned-out. She thought back to her orientation just a few months ago, when she and her fellow interns received many assurances from the program directors that the department would strictly adhere to the 80-hour work-week limitations. Those pledges, however, were followed by a speech from Dr. Thompson, the chair of the department and a world-renowned surgeon, who emphasized the importance of devotion to patient care and the field of surgery. One phrase in particular stood out during his speech to the incoming interns: “Great surgeons are those who see the extra patient, scrub in on the extra hour."

Darren, a particularly aggressive member of the intern class, had taken to working well beyond his 80 hours each week while underreporting his hours. His violation of the rules was obvious to his peers, but instead of receiving a reprimand from the program he was met with praise; Dr. Thompson singled him out as the hardest worker in his class and allowed him to scrub in on especially complex cases. The remaining interns found themselves forced to work nearly 100 hours on some weeks in order to avoid appearing less dedicated than Darren. Mary had resorted to underreporting her hours along with her fellow interns, and, while she felt bad about this, she knew that reporting the violation could cause her program to lose accreditation, which was a highly unfavorable outcome.

Commentary 2

As a neurosurgery resident, I became accustomed to the mantra: “Eat when you can; sleep when you can; and don’t mess with the brainstem.” The more casually one could toss off the brainstem bit, the more compelling, as if one were lumping it together with grabbing a KitKat from a vending machine or taking a catnap in the back row of M&M conference. We took the “sleep when you can” quite literally and almost as seriously as “avoiding the brainstem.” Patients would have been horrified to find out where and when we caught our desperately needed snatches of sleep during our 100-plus-hour work weeks.

One of our attending physicians was notorious for having us scrub in on the lengthiest and most tedious of craniotomies, but allowing us no role other than observer for large stretches of time while he toiled under the microscope. Many of us learned how to position our sterile selves just so on an OR stool, arms crossed, head tipped back against the wall, angled so that the scrub nurse could not see that we were asleep for minutes at a time rather than observing the micro movements of the instrument tips on the television monitor. We would marvel at one another’s ability to sleep during these cases as we peeked in on each other from the hallway, stifling our laughter.

The neurosurgery program I trained in was the largest in the country at the time. At one point, our chairman started a new policy: the on-call resident would call him at 9 p.m. with a brief update. He wanted to keep closer tabs on our behemoth service. I remember a several-month period when we had a particularly large number of patients, during which I would have to break free from routine evening rounds in order to call the chairman. Our entire team was still rounding at 9 p.m., generating new to-do items that would land us home at 11 p.m. (“Sorry to wake you up, Mrs. Jones. It’s 10 p.m. and time for your lumbar puncture.”) Some of us had been in the hospital since 5:30 a.m. (not to mention the resident who had been on call the previous night).

In retrospect, a quick nap in the operating room—during a case—is horrifying, and team rounds at 9 p.m. is simply ridiculous. Given my experiences as a resident prior to the work-week restrictions, I am strongly in favor of residents’ getting a healthy amount of sleep, even if forced through regulation and looked upon with contempt by certain members of the old guard. I have to admit, though, that “Eat when you can; sleep during your regulated hours off; and don’t mess with the brainstem” delivers less of a punch than the original version.

But how can an 80-hour work week be enforced in surgery training? As Mary the intern has discovered, the traditional culture of surgery, with its extreme dedication, bravado, and competition, will not be stuffed easily into the tight mold and the new culture of regulation.

With the passing of the old guard, for better or for worse, enforcement will come more naturally. When the Dr. Thompsons of the attending world are no longer in charge, the Darrens of the intern world will be less motivated to violate the rules. But what can be done during this awkward period of culture clash, with the slow changing of the guard?

I sympathize with Mary, and I do have a suggestion for her. Use the military-like hierarchy of residency to your advantage. Interns don’t have much clout. Appeal to the most well-respected and sympathetic senior or chief resident, and have him or her convey the strong concern regarding violations to the program director, as well as to Dr. Thompson himself. This indirect route, which may seem passive or even cowardly at first, accomplishes two important goals. It prevents Mary and her like-minded interns from having to worry about “appearing weak” in front of their attendings (sadly, a potential career threat) or having to play the direct whistle-blower role so early in their long training. It also allows her and her colleagues to preserve at least cordial relations with Darren, which is important while looking ahead to several years in the trenches together.

Interestingly, I have also found that appealing to a well-respected nurse or other allied professional can have a powerful influence on certain senior surgeons. Some surgeons have spent 1 or 2 decades working with the same ICU or OR nurses and maintain close professional bonds with them. These nurses are more likely to witness the questionable behavior or judgment of an intern who has been working those extra hours, sleep deprived. If such a nurse can act as an ally in Mary’s desire to monitor work-hour violations, chances for enforcement may be greater. Dr. Thompson or the program director is likely to take that nurse’s concerns seriously.

Tangentially, I recall that the most tangled of ethical violations during my own training—a resident colleague’s use of intravenous drugs while on call and caring for patients—was uncovered and reported by a perceptive emergency department nurse, based on a series of unusual clues. In retrospect, many of us had noted subtle signs ourselves, but failed to piece together the clues or to act on our suspicions.

Failing these indirect but potentially more powerful approaches—appealing to a more senior resident or allied health professional—Mary may need to report the violations herself, despite the social or professional risks.

Whatever the approach, I firmly believe that the work-week violations cannot simply be swept under the rug. Fear of losing accreditation does not justify inaction, and nipping the problem in the bud is the only way to go. As a simple exercise, Mary should try the classic New York Times test. Suppose a grave and preventable medical error were made by Darren or another sleep-deprived intern and hit the front page of the New York Timesin an explosive expose. The resourceful Times reporter then uncovered longstanding and unreported violations of work-week limitations. If Mary had failed to report these violations, how would she feel about her inaction (and, of course, the medical error itself)? Your personal and professional actions—or inactions—should always be able to withstand this effective, albeit contrived, test.

And here is one final, even simpler test: pretend that you are a patient. You find yourself sitting, cold and vulnerable in your flimsy gown, in the pre-operative holding area. The resident who will be scrubbing in on your case walks in and introduces herself. With nervous laughter, forcing a smile, you say, “Hope you got enough sleep last night!” She nods, tentatively. You’re not convinced.