Academic Physicians Just Don’t Get It!
James F. Brennan, MD, FAAPLee-Davis Pediatrics Mechanicsville, VA 23111-3682, USA
To the Editor.—
As a practicing pediatrician for 25 years, I would like to respond to Drs Moreno and Bergman’s commentary on "Resident Stress." Residency training should prepare one to enter private practice, and, I fear, if residency training is softened too much, it will rob physicians in training of much valuable experience.
Dr Moreno notes: "Residents will always struggle with setting a balance between their personal and professional lives." This struggle does not diminish or disappear when one enters practice.
They add: "The adage that patient needs invariably take precedence over family needs" is in fact the nature of what we do. As physicians we accept a commitment to those who entrust their care to us, and we and our spouses need to come to grips with this reality early in our training.
In regard to pagers, paperwork, dealing with insurance companies, coordinating patient care with specialists, etc, as a practicing physician, I deal with these things every day. Is it wrong that physicians in training are learning to handle these things?
And in regard to "shift" work: it’s nice work if you can get it. In practice, you get up; make hospital rounds; see patients in the office for 8 hours; do paperwork; make follow-up phone calls after hours; if on call, answer your pager at all hours, finding the strength to ask the right questions and give sound advice at 2 
; go to a delivery or the emergency department in the middle of the night (sometimes more than once); get up at 6 to make rounds; and return to the office to see patients for another 8 hours.
There is a value to testing your skills and endurance for long hours under the supervision of senior residents and attendings in preparation for the real life of private practice.
I am afraid that most of today’s residents are in for a real shock when they enter private practice. One doesn’t train for a marathon by running around the block.
Megan A. Moreno, MD
University of Wisconsin Madison, WI 53705, USA
In Reply.—
Dr Brennan’s astute comments raise the important concern that decreased resident work hours may leave the graduating resident unprepared for the demands of a busy private practice. Because residents in training now grow accustomed to working no more than 24- to 30-hour stretches, these same residents may find themselves unprepared to take jobs in which they are regularly expected to work 36-hour shifts.
In considering these concerns, I find myself turning to evidence-based medicine. There is a vast amount of medical literature that documents increased risks for motor vehicle accidents,1–3 depression,4,5 pregnancy complications,6,7 medical errors,8,9 and decreased empathy towards patients10 associated with prolonged work hours. This extensive evidence contributed to the present resident work-hour rules. When considering these data, one has to ask: "Is it healthy for me or my patients if I work 36 hours in a row on a regular basis? Am I offering patients the same standard of care at hour 35 as I was at hour 3?" If we are concerned that regularly working 36-hour shifts is harmful for residents as well as patients under their care, should we consider whether this is an issue for the pediatric profession as a whole? Perhaps the enlightenment that has finally reached residency programs should be extended into the practice setting. Dr Brennan may be right that long work hours during residency can prepare one for heroic work hours in a private practice, but one wonders why he is not advocating for improved hours in the practice setting.
REFERENCES
- Lowry RT. An end-of-shift tale. Ann Emerg Med.1998; 31 :287 –288[Web of Science][Medline]
- Worth R. Exhaustion that kills: why residents are still overworked—and what we can do about it. Washington Monthly.Jan/Feb 1999; 15 –20
- Marcus CL, Loughlin GM. Effect of sleep deprivation on driving safety in housestaff. Sleep1996; 10 :763 –766
- Valko RJ, Clayton PJ. Depression in the internship. Dis Nerv Syst.1975; 36 :26 –29[Web of Science][Medline]
- Reuben DB. Depressive symptoms in medical house officers: effects of level of training and work rotation. Arch Intern Med.1985; 145
:286
–288
[Abstract/Free Full Text] - Phelan ST. Pregnancy during residency: I. The decision "to be or not to be." Obstet Gynecol.1988; 72 :425 –431[Web of Science][Medline]
- Klebanoff MA, Shiono PH, Rhoads GG. Spontaneous and induced abortion among resident physicians. JAMA.1991; 261 :2821 –2825
- Davidson D, Reid K. Fatigue, alcohol and performance impairment. Nature.1997; 388 :235[Medline]
- Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA.1991; 265
:2089
–2094
[Abstract/Free Full Text] - Surgeons in training, running on empty; young doctors spend 110 hours per week or more doing their residencies [transcript]. "Nightline." ABC television. September 28,2000
James F. Brennan, MD, FAAP
Lee-Davis Pediatrics Mechanicsville, VA 23111-3682, USA
In Reply.—
Thank you for forwarding Dr Moreno’s response. Once again, my point is proven: academic physicians just don’t get it.
Private practice is a business. Our revenue to run this business is: 1) generated by the number of patient visits; 2) limited by outside sources (insurers); and 3) generated during "normal business hours." Hiring a physician to cover our "shift" is not economically feasible; Besides, patients expect personal care from their personal physician.
The economic reality of the business of medical care delivery does not afford us the luxury of "improved hours." And I don’t think the American public would accept any adaptation of the Canadian health care system.
Thank you for your time. No response is necessary.
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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