Bittersweet Symphony

In response to the studies published in the New England Journal of Medicine citing sleep deprivation as a source for decision-making mistakes, Abigail Zuger wrote an article published in last week's NY Times contrasting two interns she supervised. The man worked within his limits, viewed the care of his patients as a shared responsibility, made sure he stayed under the work limits specified by law, and never 'went the extra mile'. The woman, on the other hand, is portrayed as heroic being - always staying longer than required, doing the work of other staff, sacrificing her personal life for medicine, and viewing the care of her patients are her exclusive responsibility. The article ends on a note of nostalgia for the 'old ways' before work hours became a legal issue by concluding that medicine needs more people like the woman.

My month with the intern of the past and the intern of the future certainly argues for the power of the individual work ethic. Try as I might, it was not within my power to modify the way either of them functioned. The woman cared too much. The man cared too little. She worked too hard, and he could not be prodded into working hard enough. They both made careless mistakes. When patients died, the man shrugged and the woman cried. If for no other reason than that one, let us hope that the medicine of the future still has room for people like her.

As much as it might tug on heartstrings, things are a bit more complicated. The implication the author makes is that work hour limits will somehow prevent empathetic, dedicated physicians like the female intern from entering the field. Lifestyle considerations do not necessarily lead to undedicated doctors. There are incentives in both directions. It is just as likely that more people who would make caring physicians are being driven away to other fields due to the exhaustive lifestyle than are being drawn to it. And that the types of personalities that are attracted to the high workload are not necessarily in the best interests of health care teams or patients.

Nor is it clear to me that the obvious 'better' intern is the woman. Sure, I would not want my doctor to be like the male doctor 'slacker'. But I also certainly would not want my doctor to think she is responsible for doing others' jobs, be hyperemotional, not see my care as a team effort, or overwork herself to the point of exhaustion. It's a shame that the author of the article treats these traits as heroic. Unless medicine embraces the "change in the ethos of medicine", adjusts to the economic realities of the modern era, and allows the benefits of a complex division of labor to be tapped, it will continue to drive away talented people to other fields and place patients at higher risk than necessary.

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I agree, Jonathan. Zuger is

I agree, Jonathan. Zuger is romanticizing the situation. She wonders whether medicine has a place for people willing to go the extra mile. Last I checked, very few systems discourage people from doing free work.

The noble overworking intern doesn't manage her time well. She shouldn't be tracking down salt-free pickles and feeding patients. Delegating these tasks isn't legalism, it's minimal efficiency.

Doctors who think they can transcend mundane physiological limits are kidding themselves. No one, no mater how smart, how tough, or how dedicated can work that hard indefinitely without sacrificing performance. It's one thing to rise to the occasion and push oneself to the limit during a crunch. It's quite another to operate at an unsustainable pace all the time. Systems that encourage those tendencies are undermining medicine, not strengthening it. The system should be designed to help people function at their best.

Medblogs Grand Rounds 7,

Medblogs Grand Rounds 7, Here!
Welcome to Medblogs Grand Rounds, a weekly rotating compendium of posts by the medically minded. Here you'll find writings from many different perspectives about medicine, patients, and thoughts about the medical parts of comic books (really). Thus fa...

Frankly, the female doctor

Frankly, the female doctor should get married to a rich fellow doctor, make babies and spend her days searching out salt-free pickles for them. I don't thnk I have ever seen a worse case of poorly disuised maternal sublimation than this.

Medblogs Grand Rounds 7,

Medblogs Grand Rounds 7, Here!
Welcome to Medblogs Grand Rounds, a weekly rotating compendium of posts by the medically minded. Here you'll find writings from many different perspectives about medicine, patients, and thoughts about the medical parts of comic books (really). Thus fa...