There is also the lost opportunity cost. The student who can’t work beyond 9 hours took the place of a student who maybe had slightly worse grades but who would be dedicated and hard working. Medicine isn’t 9 hour shift work no matter what specialty is chosen.
To me, one of the most disappointing aspects of this is that it robs the student of the opportunity to develop self confidence and to find what they are capable of. I don’t think this can be understated. When I trained from 2009-2014 I didn’t think I could successfully manage a neurointensive care unit overnight by myself during a 30 hour shift. But looking back 10+ years later, these are the experiences that I remember and, more importantly, gave me the confidence and knowledge to handle other serious and complex situations. This is absolutely the administrators fault. They need to push back and realize they are not helping students by accommodating, they are actively harming them.
I remember ending a similar CCU shift during the same timeframe, fudging my fully sleepless 30 hours up to 32 so I could float a Swan. Fell asleep at a red light on the way home. Doctors have to learn how to practice when tired...that's the job. It's not ideal, but it's the job.
I blame the folks who push the concept of “work-life balance”. This is the mantra of the younger generations of docs (and other professionals), and from what I have seen, their idea of balance is tilted more heavily toward “life”. “Work”? Not so much.
I am closing in on 70, and in my clinic, the much younger docs have the mindset that this is a 9-5 gig. They are out the door before the clock hits 5:01, whether or not forms are filled out, charts are completed or phone calls are returned. Which either leaves the work undone, or leaves it for us older docs who would also like to have a life at some point, but are stuck picking up the slack.
This mindset also contributes to the overuse of emergency rooms and after hours clinics, which drives the cost of medicine up.
Let’s talk about it. Your generation handed medicine over to big business and insurance companies never stopped to pause to think about the consequences. This same generation is responsible for the understanding that the biggest enemies of physicians are …. You guessed it other physicians. I wish there was this much uproar to physician suicide and invasion of scope of practice or better yet staggering student loans or abortion rights.. accommodating our colleagues who are women and want more time to start families…. No, rather we turn our attention to a few students who have been granted a special circumstance. A majority of students in medicine show up and are prepared to work and work very hard.
We can certainly take a page from Nurses and the coalition they’ve built and how they don’t eat their own. Overuse use of emergency rooms and after hour clinics has much more to do with our kind falling asleep at the wheel and being so busy and overworked that we handed the nails and hammer over to assist big systems and private equity to put them in our coffin … Our collective mindset is a problem long before a few med students got granted 9 hour accommodation, but let’s make sure we fix this policy first and not the impending doom of our healthcare system.
I agree the takeover of private practice medicine by corporate medicine is the death knell of medical ethics, work ethic, and availability. As for ADHD some of the most productive and creative workers I know have it. They cope with it and would never ask for special favors or relief from professional responsibilities.
Medical education is being seriously dumped down(DEI) and I am going to always take the advice of an experienced busy plastic surgeon friend of mine at University who advises patients to see doctors over the age of 45.
Funny, sort of. I had several friends who were nurses when I was a resident. Some were in graduate school. Judging from what they went through trying to get their work past a committee, nurses do eat their young.
Sorry to confirm, but nurses definitely “eat their young”. Also, I have taught nursing students at Hopkins and experienced many who have accommodations that are just taking advantage of the system. It is absolutely infuriating that students think they are entitled to act however they want to and have no respect for their instructors. At the #1 nursing program in the country these students continue to be coddled and I am told to give back points on assignments. I am burned out from working for corporate medicine but I am also worried about its future with what seems like the majority students that have no common sense or respect for the profession.
I think all of what you said are salient points. What I am saying is Nurses have formed a very strong coalition. Physicians pick the wrong hill to die on. Half of our problems are self inflicted and we don’t have the spine like other coalitions to organize but rather are vocal when it comes to lowest aspect of the “totem pole”. A few students. You don’t see this behavior you describe with med students often. Most students are actually very quiet about their accommodations and show up and show out on rotations. Again wish we had this bravado with the bullies of health care and medicine in general.
I think I have to agree with you hear. Health care has become so corporatized which leads to less care because Corporations only care about the bottom line. In San Francisco, where I live, hospitals have been reduced to 3 due to huge Corporate megers.
The only way to achieve this balance, especially if you are in the trenches having fun taking care of patients (with ER service patients’ call) is with a 4-6 man group practice - a private practice not owned by a hospital. The greatest reward as a doctor is freedom to care for your patients. Money and respect of other always follow in sufficiency. Forget pursuing great wealth, or find that with clever investments.
Agreed. Generally not possible in small town or rural practices though. There are only 4 docs in the town where I have practiced since ‘93, and I’m 69. 2 of the other docs are older than me, the 4th is in his early 30s. There are also a couple of young midlevels. We are split between 3 offices. We have tried in the past to blend our practices into one but it hasn’t worked out. We have always covered for each other evenings, weekends, holidays and vacations though. It’s an informal arrangement and has always worked well…until recently. Now, it seems that taking calls before or after hours is too much of an encroachment on the personal time of the youngsters and they are often “not reachable”. So those calls get passed on to anyone else who is available.
I agree with your views on wealth. Never really was that important to me (which is what led me to start a rural practice) and at my age, it’s never gonna happen. I’m lucky enough to be able to pay my bills and my overhead and that’s OK.
I struggle with this article, and am of two minds. I am an older medical student (soon to be graduate), and I feel I straddle two generations in medicine - that of the total sacrifice of self for medicine and that of the malingering medical student looking for a 9 hr accommodation. Students today certainly make absurd demands of the field, but, the field of medicine is also making increasingly outrageous demands of physicians. Medical schools tell us “participate in 12 hours of modules on diversity and inclusion in medicine or we won’t let you graduate”. We are expected to make incessant accommodations for our patients, for our administrators, for our hospital systems. At what point do physicians have the right to an accommodation as well?
HMMK Your job is to get through it, keep your eye on the ball which is to get that piece of paper so you can do something really useful with your life. The doctor patient relationship is unique among professions in that it allows - even depends on - dealing with the most intimate and important aspects of a complete stranger’s life and health. Don’t be sidetracked by such nonsense as 12 hours of DEI training - maybe some of that will help make you a better doc. Once you get into the real medical world, whic still is a meritocracy, you will need all the facts and experience you can consume in these 4 years.
And BTW, try to minimize debt. Maximum pleasure from your work requires maxdmum freedom of choice - including that of avoiding corporate medicine. Hospitals own you and your ethics by paying off your inflated medical school debts.
As a psychologist who has diagnosed and worked with many ADHD children, adolescents, and a few adults, I have mixed feelings about this. The two words that bothered me the most are "character," and "excuse." Because ADHD is not a physical disability one can directly observe, in my experience, far too many people still question its existence, and attribute its manifestations to a character flaw, while viewing requests for accommodations as self-entitled excuse making. On the other hand, when it comes to jobs in which lives are on the line (law enforcement, medicine, fire fighters), one also must consider whether the person can perform the job to standards, and courts have definitely supported this argument. (It is not discrimination to reject a job applicant in a wheelchair from being a firefighter). "An employer is required to provide an accommodation only if it is 'reasonable'...courts
have not been generous in their definition of what is reasonable." (link below) Medical schools may need to be more explicit about their training standards along with the rationale for each standard, but in general, odds are the employer/school would win in court. I don't know this particular person, and whether the medical profession would be losing a potentially great doctor or avoiding a disaster. That needs to be done on a case-by-case basis. If a person with ADHD is sued for malpractice, their disability would not be allowed as a defense.
The octopus arms of entitlement are strangling every area of our world that is trying to be run by the fringe group of ITS ALL ABOUT ME. Like a good parent we must learn to say NO when it's not in the best interest of the whole and either they choose to up their personal standards or let them walk. These kinds of accommodations only breeds the necessity for more.
Thank you Marsha for putting thoughts out there in plain language. We were just talking today about what people are like from age 45 and younger compared to 46 and older. To me the differences are miles high and wide. I watched my dad's work philosophy and ethics. He instilled them into me. I instilled them into my children who are that cusp of 45 +/-. I totally agree with the arms of entitlement and the It's All About Me factors. Frankly I just don't want to live long enough to watch all of this ....--.... blow up in someone's face
Ok, I can see 9 hours being too short, but I wish everyone were forced to leave after a maximum of 12 hour shifts. Too many mistakes made when you're not at your best, and the ridiculous army-bootcamp attitude towards making everyone doing long shifts keeps the industry from acknowledging this problem.
I agree and disagree with the 12 shifts. I think it's doable to stay longer if people were not pressed into doing more work than one person can do just for the sake of not hiring more personnel which depletes the bottom line which depletes the "top floor". Hire the number of staff needed to work those hours in that location. They certainly know what the average day/week/month looks like and how the staffing has been... well, you know.
In so many of these situations, we don't think of the downstream effects. One was suggested in the article: in residency, all the colleagues that will have to pick up the student's slack. In the real world, beyond the magical world of academia, we need to think of the patients whose care will be abandoned because the student hit or is close to the magic hour of rest. Our society and culture has become far too fixated on the wants (not needs) of the individual to the detriment of the whole community. For medicine, accommodating this student has a high risk of injuring a lot of the patients she supposedly wants to help. Medicine is a cruel task-master.
I knew going into nursing that the hours would suck, the pay would suck, my work-life balance would be askew, but I was born to be a nurse. I am proud to be a nurse, and I wouldn't want any other career or do-over. I went into this with my eyes wide open and willingly.
There is no proof that making students work 16 hour shifts produce better doctors. The only reason why doctors think that is because “that’s the way it’s always been done.”
I bet if you did an RCT with different levels of hours of work/study, you wouldn’t find any difference in the end result of doctors qualifications.
I have ADHD. I never had reduced hours for it during training(1994 to 2001). If anything, the "H" gives you more energy. I can see adding a 30 minute break to walk and recharge, but there's no reason to decrease hours. I suspect there may be some other diagnosis like depression. All of my current partners in family medicine work about 10 hour days, 8 to 6. I do agree my 36 hour shifts were unnecessary, but 9 hours doesn't seem realistic either.
I agree. I am not an ADHD specialist, nor do I have ADHD, but i’ve seen a few adults with ADHD that had other problems as well. Now these were people who were working full time and had at least a high school education, if not s/w more.
Almost all of them used stimulants on a prn basis, and had done so since adolescence. If they were diagnosed during childhood, they had been maintained on a regular dosage schedule during that time. This undoubtedly helped them to learn the basics in math, language and science.
The ones who opted to use stimulants on a prn basis would often increase their dose (that is, return to the schedule as prescribed) when schedules or demands were tight. After the pressure was off, most returned to prn use. In my “cohort”, none abused the stimulants—or developed tolerance (which wouldn’t be expected any way). All of them had found ways to make their ADHD work for them. These folks can have a “hyper-focus” which is the ability to concentrate to the exclusion of almost everything else. This can have its advantages. Generally, they excel at computers.
Where they run into problems is with close working or love relationships. They tend to be s/w unreliable in keeping promises. I saw at least one man who, upon taking Adderall , began to notice things in his “surround”—like the trash that needed to be taken out or the dirty dishes that needed to be washed. He began to do these things to the surprise and pleasure of his wife. He had to stop the Adderall but apparently had incorporated these learned behaviors because he continued to do them. The positive reaction from his wife was probably a powerful reinforcement.
Generally, I’d say, they aren’t stellar in the empathy dept., at least initially. They can be remiss in engaging in sexual behavior—they seem to “forget” about it, which can cause problems if they’re in a relationship.
So, I don’t understand why this student had to be accommodated. Using the medication (as prescribed) creates its own accommodation.
I think there may be a tendency to grant students accommodations that they don’t strictly need.
A woman in my residency group was deaf but could hear with aids. She said she needed a fixed number of hours of sleep. She said she developed vertigo if she didn’t get the required sleep. She didn’t drive and would persuade others to take her places. I began to suspect that her “helpers” felt guilty if they didn’t help her, given that she had a disability. When she slept, even on call, she’d take out her aids, and thus couldn’t be reached. The university accommodated her somewhat by installing special telephones and allowing her to work reduced hours, especially during internship. One day, she came to me quite upset. Her two “proctors” in a family medicine rotation had failed her saying that she couldn’t or didn’t do the work. I became upset on her behalf b/c I still liked her then.
In giving it more consideration, tho’, I thought that if she couldn’t/wouldn’t do basic assessment tasks, then how could she function as a physician?
We had a falling out over her manipulation, and I believe she did finish. Her goal was to work with deaf children and perhaps that’s what she did. I may sound like a bigot, especially in these heightened anti-semitic times, but she was Jewish and played that card well. She took Saturdays off, although, to my knowledge, she was not Orthodox. I believe one of her parents was a Holocaust survivor and she claimed generational trauma from that.
In thinking about her situation now, I wonder if she would have a better fit in a less demanding field. She could teach in a deaf school or even become a clinical psychologist for the deaf. The demands to become a Ph.D psychologist are less arduous—at least physically.
Where I’m going with this is to discuss the difficulty admission committees have in selecting candidates for medical school. Gone are the days when only healthy white men (and the occasional woman) were admitted. Perhaps this contributed to some of the distortions in the field, and the resulting skewed life balance.
Some have argued essentially that there should be no balance at least in training, when staying an extra hour or two allowed one the experience of placing a Swann-Ganz, or the experience of resecting an aortic aneurysm. Maybe true, but does the need for Swan Ganz catheters or the need for a resection of an aortic aneurysm always happen late at night?
I’ve had more than my share of “peak” experiences, and they do seem to happen at odd hours. What’s more, what happened is intensely burned into my memory. For instance, I will never forget how to place a chest tube or intubate someone. So I do have some sympathy for this POV. But are such experiences essential to becoming a competent physician? IDK.
Physicians all fall on the obsessive-compulsive spectrum which is a mostly good thing. Don’t you want a somewhat obsessive physician? I do.
But the extremes of that and another common medical trait, perfectionism, can cause big trouble in other areas of the physician’s life. The high suicide/divorce rate among physicians has undoubtedly contributed to the notion of “work life balance,” and once that is established, you are pretty well down the road toward various accommodations.
This is, obviously, a slippery slope in both directions. Being overly harsh and restrictive can result in exclusion of persons of varied experience and backgrounds.
Being too loose results in ridiculous, manipulated (out of guilt?) accommodations.
Also, racism and sexism do well in restricted environments. IQ, for instance is NOT a test of global intelligence but rather a test of mental capacity. Other more specific IQ tests can further hone in on nascent abilities in math, science and language. Also, the various IQ tests (Stanford-Binet, the Weschler Adult Intelligence Scale) have long been known to be culturally biased.
Alternative ways of looking at phenomena are not tolerated in medicine as it stands. Perhaps a knowledge of indigenous healing methods (there was a Navajo in my med school class) or cultural inflences and methods
Agree with Peaches LeToure. However, as a 66 y/o soon to be retired orthopaedic surgeon, I’ve seen many bad doctors who have come through the prior less accommodating system. So it’s possible the substitution of the time-limited student for the time-unlimited, but perhaps, poor candidate was a good one. (Just look at the news and follow activities relevant to our current 2024 situation about physician misdeeds). My medical school, residency and fellowship years were not influenced by time limits. I loved what I was learning and doing and did not want limits. Later, as a young practicing physician, I had to find a balance of work, family, recreation and other activities. My choices were unique for me as I am sure is the case for all other physicians. Today, there seem to be many more graduating physicians who seek out employed positions, work in non-clinical roles in corporations and perhaps other jobs. This 9 hour time-limited student might end up being a very net-positive addition to help improve our circumstances in ways we cannot see now. I suspect the best answer might be to make select accommodations for good reasons and avoid allowing abuses to occur.
I’ve had many a discussion with patients regarding the topic of how one chooses a physician. Ultimately, my current discussion involves explaining that the titles after someone's name by themselves do not provide enlightenment regarding that choice. Ethics, honesty, concern, compassion, dedication, knowledge base, technical skills and others a far more important. The trick for patients ( and medical school admissions committees) is learning how to judge those qualities.
It is flat out wrong. I still believe that residencies should add an extra year or 2, (depending on program), given the imposed limits on resident work hours, the last decade or so. As an aside, my son suffers with ADD, and medicine has dramatically improved his academics from C’s to A/B’s; since high school, I’ve told him your professors and employers don’t care about your diagnosis- they only care about whether you can do the work/job, as you get older. Never use your condition as an excuse or crutch. With this scenario, there are nonstimulants medicines that last all day, unlike the 8-10 hour effect of most long acting stimulants. Unlike you, I don’t believe that there will be enough good doctors when I’m retired (I trained from 88-96)- I remain a pessimist on current training of physicians. We shall see.
You know old philosophers thought writing things down would make people dumber and unable to memorize things? I just find the back in my day arguments so out of touch with progress and change. Just because you can't see the new future doesn't mean it won't work out.
The 80-hour work week for residents began in 2003. This is wise because fatigue can lead to poor decision-making, but following a patient for 36 hours can teach us a great deal about disease progression. I remember my shock as an attending when a resident left in the middle of a code because they had hit the 80-hour mark. So, does a 9-hour work day for a resident surprise me? No. Where can I sign up? Future doctors may find a better work-life balance than those who trained in the past. I only hope that patient care is not compromised in that trade-off.
I started residency in 2003 when the 80 hour work week limit was just beginning. There was no real EMR in those days and we signed our names (illegibly) and then used our name stamps. When we hit 80 hours we would switch stampers for someone else’s in order to keep working. Was that a good idea? I don’t know. At the time it was just what we did. As other people have stated, you cannot just walk out the door when your hours are up if the work isn’t done. Because the “work” is real life human beings who depend on you
I would not wish to ride on a bus where the driver had been working flat out for 12 hours, so why would I want to see a stressed out and fatigued doctor?
Our graveyards are littered with the mistakes that doctors have made through an excess of diligence. I'd rather take my chances with the old medical school mantra of ' Masterly inactivity' - because most conditions sort themselves out anyway. https://www.bmj.com/content/378/bmj.o2305/rr-0
Broadly speaking, 80 hour work weeks are a form of feudal slavery, designed to control and intimidate juniors into obedience and compliance. They crush the weak, and embolden the strong - leading to a brutal hierarchy of macho heroic surgeons, and the removal of kind, caring, and nice students. Not good.
Years ago a good friend was Chief Resident in surgery at a large university hospital in Los Angeles and a first year resident told him that he couldn't make it to Saturday rounds or take call because his religion forbade driving or riding in a motor vehicle and he lived several miles away from the hospital and it was a 2-3 hour walk. My friend responded that he understood and told him, if he wanted to be a doctor, he would just have to get up that much earlier in order to get there on time.
Many years ago we had an orthodox student come on service. When Friday call was coming up he announced he couldn’t work that shift. We suggested he ask our attending who was a Distinguished Professor at the VA. He had also been a guest of the SS for years in Czechoslovakia. The professor said,”Vhat are studying to be? A doctor or a rabbi? Of course you will take call with your colleagues. They will be happy to turn off your lights or turn on your razor.” He took call with us and performed admirably.
There is also the lost opportunity cost. The student who can’t work beyond 9 hours took the place of a student who maybe had slightly worse grades but who would be dedicated and hard working. Medicine isn’t 9 hour shift work no matter what specialty is chosen.
To me, one of the most disappointing aspects of this is that it robs the student of the opportunity to develop self confidence and to find what they are capable of. I don’t think this can be understated. When I trained from 2009-2014 I didn’t think I could successfully manage a neurointensive care unit overnight by myself during a 30 hour shift. But looking back 10+ years later, these are the experiences that I remember and, more importantly, gave me the confidence and knowledge to handle other serious and complex situations. This is absolutely the administrators fault. They need to push back and realize they are not helping students by accommodating, they are actively harming them.
I remember ending a similar CCU shift during the same timeframe, fudging my fully sleepless 30 hours up to 32 so I could float a Swan. Fell asleep at a red light on the way home. Doctors have to learn how to practice when tired...that's the job. It's not ideal, but it's the job.
I blame the folks who push the concept of “work-life balance”. This is the mantra of the younger generations of docs (and other professionals), and from what I have seen, their idea of balance is tilted more heavily toward “life”. “Work”? Not so much.
I am closing in on 70, and in my clinic, the much younger docs have the mindset that this is a 9-5 gig. They are out the door before the clock hits 5:01, whether or not forms are filled out, charts are completed or phone calls are returned. Which either leaves the work undone, or leaves it for us older docs who would also like to have a life at some point, but are stuck picking up the slack.
This mindset also contributes to the overuse of emergency rooms and after hours clinics, which drives the cost of medicine up.
Let’s talk about it. Your generation handed medicine over to big business and insurance companies never stopped to pause to think about the consequences. This same generation is responsible for the understanding that the biggest enemies of physicians are …. You guessed it other physicians. I wish there was this much uproar to physician suicide and invasion of scope of practice or better yet staggering student loans or abortion rights.. accommodating our colleagues who are women and want more time to start families…. No, rather we turn our attention to a few students who have been granted a special circumstance. A majority of students in medicine show up and are prepared to work and work very hard.
We can certainly take a page from Nurses and the coalition they’ve built and how they don’t eat their own. Overuse use of emergency rooms and after hour clinics has much more to do with our kind falling asleep at the wheel and being so busy and overworked that we handed the nails and hammer over to assist big systems and private equity to put them in our coffin … Our collective mindset is a problem long before a few med students got granted 9 hour accommodation, but let’s make sure we fix this policy first and not the impending doom of our healthcare system.
I have a friend who's a nurse and she's assured me that "nurses eat their young".
I agree the takeover of private practice medicine by corporate medicine is the death knell of medical ethics, work ethic, and availability. As for ADHD some of the most productive and creative workers I know have it. They cope with it and would never ask for special favors or relief from professional responsibilities.
Medical education is being seriously dumped down(DEI) and I am going to always take the advice of an experienced busy plastic surgeon friend of mine at University who advises patients to see doctors over the age of 45.
Funny, sort of. I had several friends who were nurses when I was a resident. Some were in graduate school. Judging from what they went through trying to get their work past a committee, nurses do eat their young.
Not the way we do.
Sorry to confirm, but nurses definitely “eat their young”. Also, I have taught nursing students at Hopkins and experienced many who have accommodations that are just taking advantage of the system. It is absolutely infuriating that students think they are entitled to act however they want to and have no respect for their instructors. At the #1 nursing program in the country these students continue to be coddled and I am told to give back points on assignments. I am burned out from working for corporate medicine but I am also worried about its future with what seems like the majority students that have no common sense or respect for the profession.
I think all of what you said are salient points. What I am saying is Nurses have formed a very strong coalition. Physicians pick the wrong hill to die on. Half of our problems are self inflicted and we don’t have the spine like other coalitions to organize but rather are vocal when it comes to lowest aspect of the “totem pole”. A few students. You don’t see this behavior you describe with med students often. Most students are actually very quiet about their accommodations and show up and show out on rotations. Again wish we had this bravado with the bullies of health care and medicine in general.
I think I have to agree with you hear. Health care has become so corporatized which leads to less care because Corporations only care about the bottom line. In San Francisco, where I live, hospitals have been reduced to 3 due to huge Corporate megers.
The only way to achieve this balance, especially if you are in the trenches having fun taking care of patients (with ER service patients’ call) is with a 4-6 man group practice - a private practice not owned by a hospital. The greatest reward as a doctor is freedom to care for your patients. Money and respect of other always follow in sufficiency. Forget pursuing great wealth, or find that with clever investments.
Agreed. Generally not possible in small town or rural practices though. There are only 4 docs in the town where I have practiced since ‘93, and I’m 69. 2 of the other docs are older than me, the 4th is in his early 30s. There are also a couple of young midlevels. We are split between 3 offices. We have tried in the past to blend our practices into one but it hasn’t worked out. We have always covered for each other evenings, weekends, holidays and vacations though. It’s an informal arrangement and has always worked well…until recently. Now, it seems that taking calls before or after hours is too much of an encroachment on the personal time of the youngsters and they are often “not reachable”. So those calls get passed on to anyone else who is available.
I agree with your views on wealth. Never really was that important to me (which is what led me to start a rural practice) and at my age, it’s never gonna happen. I’m lucky enough to be able to pay my bills and my overhead and that’s OK.
I struggle with this article, and am of two minds. I am an older medical student (soon to be graduate), and I feel I straddle two generations in medicine - that of the total sacrifice of self for medicine and that of the malingering medical student looking for a 9 hr accommodation. Students today certainly make absurd demands of the field, but, the field of medicine is also making increasingly outrageous demands of physicians. Medical schools tell us “participate in 12 hours of modules on diversity and inclusion in medicine or we won’t let you graduate”. We are expected to make incessant accommodations for our patients, for our administrators, for our hospital systems. At what point do physicians have the right to an accommodation as well?
Excellent food for thought, thank you.
HMMK Your job is to get through it, keep your eye on the ball which is to get that piece of paper so you can do something really useful with your life. The doctor patient relationship is unique among professions in that it allows - even depends on - dealing with the most intimate and important aspects of a complete stranger’s life and health. Don’t be sidetracked by such nonsense as 12 hours of DEI training - maybe some of that will help make you a better doc. Once you get into the real medical world, whic still is a meritocracy, you will need all the facts and experience you can consume in these 4 years.
And BTW, try to minimize debt. Maximum pleasure from your work requires maxdmum freedom of choice - including that of avoiding corporate medicine. Hospitals own you and your ethics by paying off your inflated medical school debts.
As a psychologist who has diagnosed and worked with many ADHD children, adolescents, and a few adults, I have mixed feelings about this. The two words that bothered me the most are "character," and "excuse." Because ADHD is not a physical disability one can directly observe, in my experience, far too many people still question its existence, and attribute its manifestations to a character flaw, while viewing requests for accommodations as self-entitled excuse making. On the other hand, when it comes to jobs in which lives are on the line (law enforcement, medicine, fire fighters), one also must consider whether the person can perform the job to standards, and courts have definitely supported this argument. (It is not discrimination to reject a job applicant in a wheelchair from being a firefighter). "An employer is required to provide an accommodation only if it is 'reasonable'...courts
have not been generous in their definition of what is reasonable." (link below) Medical schools may need to be more explicit about their training standards along with the rationale for each standard, but in general, odds are the employer/school would win in court. I don't know this particular person, and whether the medical profession would be losing a potentially great doctor or avoiding a disaster. That needs to be done on a case-by-case basis. If a person with ADHD is sued for malpractice, their disability would not be allowed as a defense.
https://chadd.org/wp-content/uploads/2018/06/ATTN_04_11_RightsInWorkplace.pdf
The octopus arms of entitlement are strangling every area of our world that is trying to be run by the fringe group of ITS ALL ABOUT ME. Like a good parent we must learn to say NO when it's not in the best interest of the whole and either they choose to up their personal standards or let them walk. These kinds of accommodations only breeds the necessity for more.
I'm waiting to hear that psychopathic med students are being granted accomodations.
Psychopathic med students take their own accommodation, whether it’s granted or not.
:):):)
Thank you Marsha for putting thoughts out there in plain language. We were just talking today about what people are like from age 45 and younger compared to 46 and older. To me the differences are miles high and wide. I watched my dad's work philosophy and ethics. He instilled them into me. I instilled them into my children who are that cusp of 45 +/-. I totally agree with the arms of entitlement and the It's All About Me factors. Frankly I just don't want to live long enough to watch all of this ....--.... blow up in someone's face
Ok, I can see 9 hours being too short, but I wish everyone were forced to leave after a maximum of 12 hour shifts. Too many mistakes made when you're not at your best, and the ridiculous army-bootcamp attitude towards making everyone doing long shifts keeps the industry from acknowledging this problem.
I agree and disagree with the 12 shifts. I think it's doable to stay longer if people were not pressed into doing more work than one person can do just for the sake of not hiring more personnel which depletes the bottom line which depletes the "top floor". Hire the number of staff needed to work those hours in that location. They certainly know what the average day/week/month looks like and how the staffing has been... well, you know.
In so many of these situations, we don't think of the downstream effects. One was suggested in the article: in residency, all the colleagues that will have to pick up the student's slack. In the real world, beyond the magical world of academia, we need to think of the patients whose care will be abandoned because the student hit or is close to the magic hour of rest. Our society and culture has become far too fixated on the wants (not needs) of the individual to the detriment of the whole community. For medicine, accommodating this student has a high risk of injuring a lot of the patients she supposedly wants to help. Medicine is a cruel task-master.
I knew going into nursing that the hours would suck, the pay would suck, my work-life balance would be askew, but I was born to be a nurse. I am proud to be a nurse, and I wouldn't want any other career or do-over. I went into this with my eyes wide open and willingly.
Wants vs. needs. 👏🏼
There is no proof that making students work 16 hour shifts produce better doctors. The only reason why doctors think that is because “that’s the way it’s always been done.”
I bet if you did an RCT with different levels of hours of work/study, you wouldn’t find any difference in the end result of doctors qualifications.
I have ADHD. I never had reduced hours for it during training(1994 to 2001). If anything, the "H" gives you more energy. I can see adding a 30 minute break to walk and recharge, but there's no reason to decrease hours. I suspect there may be some other diagnosis like depression. All of my current partners in family medicine work about 10 hour days, 8 to 6. I do agree my 36 hour shifts were unnecessary, but 9 hours doesn't seem realistic either.
I agree. I am not an ADHD specialist, nor do I have ADHD, but i’ve seen a few adults with ADHD that had other problems as well. Now these were people who were working full time and had at least a high school education, if not s/w more.
Almost all of them used stimulants on a prn basis, and had done so since adolescence. If they were diagnosed during childhood, they had been maintained on a regular dosage schedule during that time. This undoubtedly helped them to learn the basics in math, language and science.
The ones who opted to use stimulants on a prn basis would often increase their dose (that is, return to the schedule as prescribed) when schedules or demands were tight. After the pressure was off, most returned to prn use. In my “cohort”, none abused the stimulants—or developed tolerance (which wouldn’t be expected any way). All of them had found ways to make their ADHD work for them. These folks can have a “hyper-focus” which is the ability to concentrate to the exclusion of almost everything else. This can have its advantages. Generally, they excel at computers.
Where they run into problems is with close working or love relationships. They tend to be s/w unreliable in keeping promises. I saw at least one man who, upon taking Adderall , began to notice things in his “surround”—like the trash that needed to be taken out or the dirty dishes that needed to be washed. He began to do these things to the surprise and pleasure of his wife. He had to stop the Adderall but apparently had incorporated these learned behaviors because he continued to do them. The positive reaction from his wife was probably a powerful reinforcement.
Generally, I’d say, they aren’t stellar in the empathy dept., at least initially. They can be remiss in engaging in sexual behavior—they seem to “forget” about it, which can cause problems if they’re in a relationship.
So, I don’t understand why this student had to be accommodated. Using the medication (as prescribed) creates its own accommodation.
I think there may be a tendency to grant students accommodations that they don’t strictly need.
A woman in my residency group was deaf but could hear with aids. She said she needed a fixed number of hours of sleep. She said she developed vertigo if she didn’t get the required sleep. She didn’t drive and would persuade others to take her places. I began to suspect that her “helpers” felt guilty if they didn’t help her, given that she had a disability. When she slept, even on call, she’d take out her aids, and thus couldn’t be reached. The university accommodated her somewhat by installing special telephones and allowing her to work reduced hours, especially during internship. One day, she came to me quite upset. Her two “proctors” in a family medicine rotation had failed her saying that she couldn’t or didn’t do the work. I became upset on her behalf b/c I still liked her then.
In giving it more consideration, tho’, I thought that if she couldn’t/wouldn’t do basic assessment tasks, then how could she function as a physician?
We had a falling out over her manipulation, and I believe she did finish. Her goal was to work with deaf children and perhaps that’s what she did. I may sound like a bigot, especially in these heightened anti-semitic times, but she was Jewish and played that card well. She took Saturdays off, although, to my knowledge, she was not Orthodox. I believe one of her parents was a Holocaust survivor and she claimed generational trauma from that.
In thinking about her situation now, I wonder if she would have a better fit in a less demanding field. She could teach in a deaf school or even become a clinical psychologist for the deaf. The demands to become a Ph.D psychologist are less arduous—at least physically.
Where I’m going with this is to discuss the difficulty admission committees have in selecting candidates for medical school. Gone are the days when only healthy white men (and the occasional woman) were admitted. Perhaps this contributed to some of the distortions in the field, and the resulting skewed life balance.
Some have argued essentially that there should be no balance at least in training, when staying an extra hour or two allowed one the experience of placing a Swann-Ganz, or the experience of resecting an aortic aneurysm. Maybe true, but does the need for Swan Ganz catheters or the need for a resection of an aortic aneurysm always happen late at night?
I’ve had more than my share of “peak” experiences, and they do seem to happen at odd hours. What’s more, what happened is intensely burned into my memory. For instance, I will never forget how to place a chest tube or intubate someone. So I do have some sympathy for this POV. But are such experiences essential to becoming a competent physician? IDK.
Physicians all fall on the obsessive-compulsive spectrum which is a mostly good thing. Don’t you want a somewhat obsessive physician? I do.
But the extremes of that and another common medical trait, perfectionism, can cause big trouble in other areas of the physician’s life. The high suicide/divorce rate among physicians has undoubtedly contributed to the notion of “work life balance,” and once that is established, you are pretty well down the road toward various accommodations.
This is, obviously, a slippery slope in both directions. Being overly harsh and restrictive can result in exclusion of persons of varied experience and backgrounds.
Being too loose results in ridiculous, manipulated (out of guilt?) accommodations.
Also, racism and sexism do well in restricted environments. IQ, for instance is NOT a test of global intelligence but rather a test of mental capacity. Other more specific IQ tests can further hone in on nascent abilities in math, science and language. Also, the various IQ tests (Stanford-Binet, the Weschler Adult Intelligence Scale) have long been known to be culturally biased.
Alternative ways of looking at phenomena are not tolerated in medicine as it stands. Perhaps a knowledge of indigenous healing methods (there was a Navajo in my med school class) or cultural inflences and methods
(Continued) would broaden medicine leaving us less dependent on Big Pharma.
As always, we should not risk throwing the various babies out with the bath water.
Agree with Peaches LeToure. However, as a 66 y/o soon to be retired orthopaedic surgeon, I’ve seen many bad doctors who have come through the prior less accommodating system. So it’s possible the substitution of the time-limited student for the time-unlimited, but perhaps, poor candidate was a good one. (Just look at the news and follow activities relevant to our current 2024 situation about physician misdeeds). My medical school, residency and fellowship years were not influenced by time limits. I loved what I was learning and doing and did not want limits. Later, as a young practicing physician, I had to find a balance of work, family, recreation and other activities. My choices were unique for me as I am sure is the case for all other physicians. Today, there seem to be many more graduating physicians who seek out employed positions, work in non-clinical roles in corporations and perhaps other jobs. This 9 hour time-limited student might end up being a very net-positive addition to help improve our circumstances in ways we cannot see now. I suspect the best answer might be to make select accommodations for good reasons and avoid allowing abuses to occur.
I’ve had many a discussion with patients regarding the topic of how one chooses a physician. Ultimately, my current discussion involves explaining that the titles after someone's name by themselves do not provide enlightenment regarding that choice. Ethics, honesty, concern, compassion, dedication, knowledge base, technical skills and others a far more important. The trick for patients ( and medical school admissions committees) is learning how to judge those qualities.
It is flat out wrong. I still believe that residencies should add an extra year or 2, (depending on program), given the imposed limits on resident work hours, the last decade or so. As an aside, my son suffers with ADD, and medicine has dramatically improved his academics from C’s to A/B’s; since high school, I’ve told him your professors and employers don’t care about your diagnosis- they only care about whether you can do the work/job, as you get older. Never use your condition as an excuse or crutch. With this scenario, there are nonstimulants medicines that last all day, unlike the 8-10 hour effect of most long acting stimulants. Unlike you, I don’t believe that there will be enough good doctors when I’m retired (I trained from 88-96)- I remain a pessimist on current training of physicians. We shall see.
You know old philosophers thought writing things down would make people dumber and unable to memorize things? I just find the back in my day arguments so out of touch with progress and change. Just because you can't see the new future doesn't mean it won't work out.
Many female GPs in the UK work part time due to childcare responsibilities. I think you are being a bit harsh.
The 80-hour work week for residents began in 2003. This is wise because fatigue can lead to poor decision-making, but following a patient for 36 hours can teach us a great deal about disease progression. I remember my shock as an attending when a resident left in the middle of a code because they had hit the 80-hour mark. So, does a 9-hour work day for a resident surprise me? No. Where can I sign up? Future doctors may find a better work-life balance than those who trained in the past. I only hope that patient care is not compromised in that trade-off.
I started residency in 2003 when the 80 hour work week limit was just beginning. There was no real EMR in those days and we signed our names (illegibly) and then used our name stamps. When we hit 80 hours we would switch stampers for someone else’s in order to keep working. Was that a good idea? I don’t know. At the time it was just what we did. As other people have stated, you cannot just walk out the door when your hours are up if the work isn’t done. Because the “work” is real life human beings who depend on you
I would not wish to ride on a bus where the driver had been working flat out for 12 hours, so why would I want to see a stressed out and fatigued doctor?
Airline pilots are limited in the number of hours they can fly each month. But a screw-up on their parts can take out hundreds at a clip.
Our graveyards are littered with the mistakes that doctors have made through an excess of diligence. I'd rather take my chances with the old medical school mantra of ' Masterly inactivity' - because most conditions sort themselves out anyway. https://www.bmj.com/content/378/bmj.o2305/rr-0
Broadly speaking, 80 hour work weeks are a form of feudal slavery, designed to control and intimidate juniors into obedience and compliance. They crush the weak, and embolden the strong - leading to a brutal hierarchy of macho heroic surgeons, and the removal of kind, caring, and nice students. Not good.
Years ago a good friend was Chief Resident in surgery at a large university hospital in Los Angeles and a first year resident told him that he couldn't make it to Saturday rounds or take call because his religion forbade driving or riding in a motor vehicle and he lived several miles away from the hospital and it was a 2-3 hour walk. My friend responded that he understood and told him, if he wanted to be a doctor, he would just have to get up that much earlier in order to get there on time.
Many years ago we had an orthodox student come on service. When Friday call was coming up he announced he couldn’t work that shift. We suggested he ask our attending who was a Distinguished Professor at the VA. He had also been a guest of the SS for years in Czechoslovakia. The professor said,”Vhat are studying to be? A doctor or a rabbi? Of course you will take call with your colleagues. They will be happy to turn off your lights or turn on your razor.” He took call with us and performed admirably.
Yes, the message is that you will adapt to the needs of the profession rather than the other way around.
Agree with some of the comments.
Not even mentioning a 12 o 16 hours shift, I don't see why a long shift should make better students.
In Portugal, students never have long shifts. As a student, I never had a 9h shift as far as I remember (just when doing an internship in Brazil).
Am I worst doctor? I wished not.
Well, let's do a RCT to prove it?