Re-Examining the 36-Hour Day

By Claudia Wallis

The hours are endless. The pay is paltry. The tasks are often menial, the responsibilities terrifying. And for this, one must spend four years slaving in medical school and acquiring a debt that averages more than $30,000. For decades, doctors have argued the merits of medical residency -- the grueling and sleepless years of specialty training that constitute a rite of passage into American medical practice. Senior physicians defend the traditional residency as a necessary part of the toughening-up process for professionals who must deal with emergencies and late-night awakenings throughout their careers. Young residents complain that it is cruel and unusual punishment that destroys any semblance of a normal, private life and their enthusiasm for medicine. Meanwhile, in an era in which medicine has become increasingly technical and exacting, patients are alarmed that so many hospitals depend on a weary cadre of on-the-job trainees: Who wants to put his life in the hands of a novice who has been on duty for 36 consecutive hours?

In New York State, which trains 14% of the nation's doctors, the debate over how doctors are trained has exploded into action. Troubled by a rash of malpractice cases that, he says, "seem to have been related to fatigue and lack of supervision," Health Commissioner David Axelrod appointed a blue- ribbon committee of New York doctors to investigate. Axelrod had been particularly upset by the case of Libby Zion, an 18-year-old Manhattanite who died while undergoing treatment for a high fever at New York Hospital in 1984; a grand jury attributed her death to neglectful treatment by tired and undersupervised young residents.

In June, Axelrod's committee issued a report recommending improved supervision of residents and strict limits on how many hours they can work at a stretch. Residents, urged the committee, should work no more than 16 consecutive hours in ordinary, inpatient care, and no more than twelve hours in the emergency room. In today's high-tech environment, said Axelrod, "the opportunity to do good as well as to do harm is increasing. I don't know that someone who is semisomnolent can make the judgments required."

These proposals, and a similar reform effort expected to come before the California legislature next year, have doctors and hospital administrators around the country up in arms. Changing the hours and responsibilities of residents would not only alter the way doctors are trained, it would also wreak havoc with the staffing of teaching hospitals, which depend on the cheap labor of residents, who typically earn about $24,000 a year.

Last week, the Greater New York Hospital Association, which represents nonprofit hospitals in and around New York City, responded to the Axelrod initiative with its own study. While supporting the "overall intent" of the proposed reforms, G.N.Y.H.A. raised a number of problems. Limiting the hours worked by residents could create massive staffing shortages at teaching hospitals, warned the report. In addition, the cost of transferring responsibility from low-paid residents to high-salaried senior staff and implementing other reforms would be staggering: at least $200 million a year for G.N.Y.H.A.'s 70 member hospitals. The report also warned of introducing a "shift mentality" to medicine. This notion, it said, "is generally inconsistent with the delivery of high-quality patient care."

The debate in New York reflects the difficulties of changing a system that traces its roots in the U.S. to the late 1880s. Yet there is little doubt as to the need for reform. Even the American Medical Association, though adamantly opposed to state interference in medical training, acknowledges that the pressures on young doctors are now too heavy. "The A.M.A. is extremely concerned about stress and overfatigue in residency," says Dr. William Jacott, chairman of the A.M.A. Council on Medical Education. "We realize that stress is a critical part of the educational program, but we want it better under control."

Doctors generally agree that the pressures are most extreme and the hours most draining during a resident's first year, traditionally known as the internship. A typical schedule: at least five days a week, a minimum of 16 hours a day, plus being "on call" in the hospital every third night. In large big-city hospitals, those nights on call often mean 36 hours without a wink of sleep. During that crucial first year, "I was tired enough that I nodded off at the surgery table," admits Michael Longaker, who is still putting in 18-hour days as a third-year resident in cardiology at the University of California San Francisco Medical Center. During his entire year as an intern, he says, "I don't remember too many nights when I got more than three or four hours' sleep."

Chronic exhaustion coupled with enormous responsibility takes a terrible toll. While working as a resident in New York City hospitals, Joseph Sachter watched his peers literally crumple to the floor. On one occasion, he reports, a resident, on duty for nearly 24 hours, had just enough stamina to oversee safely the birth of a baby at 4 a.m. "Then he walked out of the delivery room and collapsed." The early-morning hours toward the end of a shift constitute a "danger zone" for patients, says Sachter. "When it's 5 a.m. and the case doesn't appear to be life threatening, the next thing you want to know is, Can this wait until 7 a.m.? because that's when the next resident comes in."

The emotional wear and tear for interns and residents can be worse than the physical demands: they have virtually no time for family, friends, doing household errands. Studies have shown that as many as 30% of residents become severely depressed. Other surveys indicate high rates of divorce, suicide, drug abuse and alcoholism. "People deteriorate," says Reggie Baugh, who has just finished his residency in Michigan. "Your goal is to survive the day." When a colleague attempted suicide, Baugh thought to himself, "Five more minutes and I could have been there too."

Many physicians insist, however, that the long hours of residency are a critical part of medical education. "Illness knows no shift," says Dr. Robert Petersdorf, president of the Association of American Medical Colleges. Such ailments as diabetic coma or toxic shock, he notes, can progress over 36 hours. "You have to follow the history of the particular illness." Others point out that if shifts are significantly shortened, medical residencies might have to be lengthened to ensure that trainees get enough experience. With residencies already lasting from three years for internal medicine to seven years for neurosurgery, few young doctors would warm to that prospect.

As with other boot-camp graduates, many doctors feel, If I went through it, so can you. Some of the resistance to changing medical residencies reflects this macho sentiment. Established physicians remember their years of training as dramatic and character building. The fact is, however, that the typical experience of a medical resident has changed over the decades. Thirty years ago, physicians had less information to master and fewer tools at their disposal. Nights on call tended to be less punishing, if not enjoyable. New York Obstetrician Selig Neubardt, 61, remembers playing his guitar to while away his hours on call in the 1950s. He allows that his son Seth, a resident at Montefiore Medical Center in the Bronx, "works harder than I ever did."

What has changed is not only the intensity of the training but the work itself. Today's trainees spend far more time dealing with administrative detail, owing in part to the omnipresent fear of malpractice suits. "You spend a lot of time doing paperwork because of the so-called medical-legal environment," says Lora Wiggins, an intern at Winthrop University Hospital in Mineola, Long Island. "You're exhausted, and you are dealing with two kinds of criteria for how you act." To add to the burdens, today's hospital patients tend, as a group, to be more sick than ever before. Technology has enabled extremely ill patients to linger on the brink of death for days at a time. And changes in Medicare reimbursement rules have led hospitals to release patients earlier than they used to, so that almost every bed is occupied by a very sick person.

Not all American hospitals have been indifferent to these changes and the increasing stress they place on residents. Some have instituted "night floats," fresh teams of doctors who arrive at 10 p.m. to ease the burden of those on all-night call. Others, such as Baystate Medical Center in Springfield, Mass., have established support groups for house staff to help them cope with emotional difficulties. In some cases, fear of malpractice suits has served as incentive for medical centers to limit the hours that residents spend in the emergency room or in such specialty services as anesthesiology, where the slightest error can be fatal.

In some institutions, residents have taken the initiative by forming unions to lobby for better hours. At Chicago's Cook County Hospital, for instance, the house-staff officers association managed to have call schedules reduced from every third night to once every four nights.

But changes have been slow in coming, and resistance is great. The A.M.A. has recently launched a comprehensive study of stress in residency. This December it will issue a report on the subject, making recommendations that could influence the Accreditation Council for Graduate Medical Education, the body that approves residency programs. "This is hopefully the start of a new generation of training," says Dr. Patricia Kolowich, former vice chairman of the A.M.A.'s resident-physician section.

The A.M.A. argues that only the medical profession can intelligently guide the training of its own members. But in New York, Axelrod is pushing for implementation of his proposed changes by next July. Thus the medical profession in its reluctance to heal itself may be forced to swallow the bitter pill of imposed reform.

With reporting by Cheryl Crooks/Los Angeles and Jennifer Hull/New York