 |
 |
 |
|
 |
|
 |
 |
| Illustrations by Rod Clement |
|
|
DOES THE STRESS PUT ON YOUNG DOCTORS BY FORCING THEM TO WORK LONG HOURS REALLY MAKE THEM BETTER DOCTORS?
Abuse of our fellow humans occurs in all sorts of contexts, for all sorts of motivations, and by all sorts of people.
Why?
At least part of this answer is due to an important principle by famed child abuse psychologist Dr. Alice Miller: “Abuse must be repeated, and it is”.
Miller explains that, whether the abuse occurs in childhood or later in life, the hurt remains for a lifetime. Although it is often denied, suppressed, and masked, it nevertheless shows itself in one’s behaviour somewhere---it must be repeated.
This helps explain self-destructive behaviours where people repeat the same pathological acts to the detriment of themselves and others. It helps explain why so often child abuse victims grow up to become child abuse victimizers. It may be an impetus for assaults, murders, revenge killings, ethnic cleansings, and the mass slayings by dictators. Hitler, Stalin, and Saddam Hussein were all severely physically abused as children. It may even help explain why nations that should know better, sometimes behave so badly. Today’s Israel treats innocent Palestinian children in the Gaza Strip in much the same way as yesterday’s Nazis treated innocent Jewish children in the Warsaw ghetto.
Abuse must be repeated, and it is.
Miller adds that when an abuse victim reverses roles and becomes the abuser, it is a feeble attempt to somehow make sense of, deal with, and overcome the effects of their own abuse.
Abusive behaviour shows itself in big ways and small, in our homes, our relationships, our workplaces---even in the most respected profession of all: Medicine.
Over recent years, the Harvard Work Hours, Health and Safety Group of Harvard Medical School has produced study after study showing that young doctors (interns and residents) are still forced to work marathon shifts of 80 hours or more in hospitals. This creates hazards for themselves, endangers patients, and constitutes a workplace abusive practice. As William Cromie writes in the 5 September 2006 HARVARD UNIVERSITY GAZETTE, “That intern working on you at the hospital may be so sleep-deprived his or her performance is no better than that of a drunk”.
The Harvard Group is led by Dr. Charles Czeisler and Dr. Christopher Landrigan. Their research has appeared in many places over recent years including in THE NEW ENGLAND JOURNAL OF MEDICINE, CRITICAL CARE, CRITICAL CARE MEDICINE, and THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION among others.
Research by the Harvard Group, but also by many others, shows that inexperienced doctors are more prone to make medical mistakes even under the best of circumstances. These mistakes increase further when young doctors are working while exhausted. It is estimated that under the best conditions, the care given by an inexperienced doctor will result in about a 15 per cent increase in the number of mistakes made in patient treatment compared to when an experienced doctor treats the patient. This risk doubles when the young doctor is also exhausted.
Cromie adds that the medical profession has long known that sleep-deprived doctors are dangerous, but they continue to allow the practice. In 2003, the Accreditation Council for Graduate Medical Education in the U.S. put a cap on hours that interns and residents can work to a maximum shift of 30 consecutive hours and no more than 80 hours. However, the Harvard Group surveyed hospitals and discovered that this cap has been ignored. In addition, their study in the 13 January 2005 issue of THE NEW ENGLAND JOURANL OF MEDICINE found that young doctors who work hospital shifts up to or exceeding 24 consecutive hours are more than twice as likely to be involved in a motor vehicle accident than those who do not work such shifts.
Another Harvard Group study, published in the November 2007 JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY, revealed that the same finding for doctors applies to nurses. Nurses experience the same decline in their work performance and suffer more negative health consequences. They write “Nurses working shifts greater than 12.5 hour are at significantly increased risk of experiencing decreased vigilance on the job, suffering an occupational injury, or making a medical error.
Doctors are already very likely to suffer from depression as a result of heavy work burdens. In a Brazilian study, Dr. Sergio Baldassin and three colleagues from the ABC Regional Medical School in Sao Paulo and published in the December 2008 BMC MEDICAL EDUCATION, found that 38 per cent of young doctors suffer clinical depression even when not further stressed by sleep loss brought about by long, unbroken work shifts.
Why are patients and doctors placed when everyone knows this is dangerous?
Chief defenders of marathon shifts are senior doctors who, along with administrators, are in charge of hospitals. Two reasons are given. One is public: “This is the only way to test a young doctor’s dedication”. One is private: “I had to do it, so they should too”.
The first reason is not supported by research, but only by wishful thinking by those who hold this view. It is not the important reason anyway. The second reason is the real one. The abusive marathon shifts continue for the reasons that “I had to do it, so they should too”. Senior doctors had to endure abuse when they were young doctors such that they pass on the abuse to the next generation of doctors as if it was an initiation ritual into the medical profession. Regardless of logic, the abuse must be endured when it is inflicted. It was inflicted on me, it will be inflicted on you.
Abuse must be repeated, and it is.
It would seem that this motivation in senior doctors is even greater than adhering to the Hippocratic Oath. The Oath has been the almost sacred ethical code of doctors for 2500 years. The most important rule of the Oath is Primum non nocere (“First, do no harm”). This has come to mean “never do deliberate harm to anyone for someone else’s interests”. In putting young doctors through abusive marathon shifts, senior doctors violate the Oath in three ways: By risking the patient more than necessary, by placing young doctors at health risk, and by placing the interests of the patient after those of the young doctor---whose dedication is being tested at the patient’s expense.
Abusive marathon shifts are banned in Europe. A doctor cannot work a shift longer than 13 hours. Abusive marathon shifts of young doctors are banned by law in some localities in the U.S., Canada, Australia, and New Zealand, yet the practice continues. Ask any young doctor at a public hospital in Australia, for example. Senior doctors break the civil law as well as the Oath.
Why?
Abuse must be repeated, and it is.
As Miller has described, when a victim of abuse repeats the abuse by inflicting it on others, it is a feeble attempt to somehow make sense and deal with their own abuse. Such individuals are damaged, weakened, and desperate.
What senior doctors supporting marathon shifts unknowingly communicate to junior doctors is: As I had to go through it, you do too. Yes, it makes no sense. Yes, your patients are at greater risk. Yes, you must acquiesce to the violating of the Hippocratic Oath by those above you. You must not complain, rock the boat, or do anything else but follow orders. Suffer in silence although you know it is wrong. Only then can you join this profession.
The test of dedication is really a test of one’s willingness to endure physical and psychological strain, institutional bullying, humiliation, professional blackmail, and the hypocrisy of those above them.
Lining up all young doctors and bashing them within an inch of their life and then waiting to see who comes back for more is also a “test of dedication” of sorts. It is more direct too and probably better from the standpoint of risk to patients.
Improving the procedure is easy. All involved are usually good people. But as Miller points out, people often are unaware when they act from their own abuse and often cannot bear to think of it. Repeating the abuse to overcome it can be more important than any other consideration.
There will be defenders of marathon shifts for doctors and the abuse it produces as there were those who in the past opposed anti-slavery, the flogging of convicts, anti-cruelty to animals, and anti-child abuse laws. There are those who fail to recognize abuse, deny it, or explain it away.
Abuse must be repeated, and it is---until it is stopped.
Home | About Stephen | Odd Books | Odd News | Odd Quiz | Contact
Copyright HarperCollins Publishers 2002 | Privacy Policy | Terms of Use