DUTY HOURS
Drug dealers gave up using pagers years ago, but we physicians still clip them to our belts or to the reinforced pockets of our white coats. Some female physicians slip them inside the collar of their boots, where the small black box resembles the electronic monitors that parolees wear to track their movements.
We use pagers because they are an inexpensive way to track the members of a medical team as they disperse across the warrens of a contemporary hospital. While we are on call, we send each other pages to remind ourselves which patients to revisit, what results to follow, when to admit new patients, and where to catch lunch. When a pager emits one of seven preprogrammed tunes from its tinny speaker, we all reach for our belts to see who has been called. Pagers that frequently go off are known as “dirty bombs” because they act like shrapnel, disrupting schedules and plans. When a shift ends, we quickly pass our pagers off to the next physician.
There is one pager you cannot pass off: your personal pager, the number at which you can always be reached, no matter where you are working or with whom. The personal pager represents one way the body of a physician is regulated in professional responsibilities.
. . .
Everyone agrees that physicians are professionals. We have obligations to patients that go beyond simply doing whatever we can do for a patient or doing what a patient requests us to do. We are obliged to uphold the ethical and technical standards of medicine. Humanism and professionalism may often be confused with each other, but professionalism is worth pursuing in its own right. We know that students who engage in unprofessional behavior are more likely to become physicians who engage in behavior that harms patients, so some efforts to renew medicine are aimed at fostering professionalism among students, trainees, and practicing physicians.
One effort is “Medical Professionalism in the New Millennium,” a physician charter produced by leading American and European medical organizations. The charter identifies three principles—patient welfare, patient autonomy, and social justice—and expands them into ten commitments.1 The commitments are all reasonable—engaging in lifelong learning, being honest with patients, maintaining patient confidentiality, respecting appropriate boundaries, improving the quality of care, increasing access to care, pursuing cost-effective care, appropriately using science and technology, avoiding conflicts of interest, and self-policing the profession—but toothless. The principles are abstract. The commitments are nonbinding. Few physicians even realize that their professional organizations have committed to these principles on their behalf.
The charter is an aspirational consensus statement, one of many statements and studies, centers and curricula, ideas and initiatives aimed at bolstering or inculcating professionalism among physicians. All are well intentioned. Most of them, like the charter, are concerned with the ways physicians can regulate their own behavior.
Yet none of these initiatives are as influential as the practices that regulate the time and movement of physicians. A physician can choose to engage with or ignore a charter but must respond to the systems that govern his or her time. For the past couple of decades, pagers have symbolized the kinds of governance that enforce a physician’s professional obligations.
As a medical student, I carried pagers for a series of teams named after the parts of the body for which the team cared. Hematologists. Thoracic surgeons. Pediatric cardiologists. Gynecologists. Neurologists. I joined each team for a prescribed period of time. Two weeks with the urologists. Four weeks with the oncologists. When I joined each team, I was always asked the same three questions: name, rank, and pager number. Then someone would quickly introduce everyone else on the team by name, rank, and pager number. It was like the nerd version of the meet-up scene in a war movie where a new infantry unit is assembled from the remains of several others.
When I first joined these clinical teams as a third-year med student, I figured myself for a future internist or surgeon, a physician with dramatizable skills. Internists were mapmakers, mapping patient symptoms and diagnostic test results onto unseen organs within the body, deducing what was going on inside the body without disturbing the skins. Surgeons were explorers: distrusting maps of unseen locales, they parted the veils of skin and fat to gaze directly upon diseased tissue or aberrant structures, then removed or repaired them.
As the third-year student, though, I had few skills beyond fetching coffee, charting fever curves, and debriding wounds of necrotic tissue. My job was to fit myself to the team, to pattern my actions on the members’. They approved of me when I imitated their actions. They disapproved of me when I asked why we engaged in those actions. Surgeons disliked questions on rounds because questions kept us from the battlefield of the operating room.
On the surgical team, my pager and I were assigned to a pair of towering interns. The first had a gap-toothed smile and bushy hair parted at the left; despite his hair, everyone called him Gandhi because he was so coolheaded and even-keeled. The second had short, tightly curled hair cut close to his scalp, glasses too small for his face, and perfect teeth; we called him Cannon.
Cannon never learned my name, preferring to call me Rookie, or just Rook, as if I were the PFC to his second lieutenant.
Cannon was unhappy with his place on the ladder. He had wanted to enroll at an American medical school but wound up at an international school instead. He had wanted to specialize in orthopedics but had settled for general surgery. He had hoped to train at a private hospital but wound up at a state-sponsored school where, as he ruefully noted, there were “lots of poor folks on these wards, Rook.”
Our first shift together, he promised to show me “how medicine works.” We made rounds before dawn, wrote notes through lunch, visited the operating room in the afternoon, and spent the evening admitting patients from the Emergency Department. Our schedule was frequently altered when more urgent concerns were brought to our attention by our pagers.
Around three in the morning, a nurse paged us about one of our team’s postoperative patients. The patient had intractable hiccups that kept her from sleeping.
I summarized the concern and asked Cannon, “What should we do for the hiccupping lady?”
“Tell the nurse hiccups are not a surgical problem.”
“But it’s our patient.”
“Okay, Rook, look up the treatments for intractable hiccups.”
I opened the computer, searched online for the treatments, and read them aloud, “Chlorpromazine. Haloperidol. Methylphenidate. Baclofen. Midazolam. Rectal massage.”
“What was that last one?”
“Rectal massage.”
“Uh-huh. That’s the one. Rook, let me teach you. You’ve got to show the nurse who is in charge. Call them and tell them we want PRN rectal massage to treat those hiccups.”
“No way.”
“Wuss. I’ll call.”
Cannon did. The nurses were angry, but he insisted. Rectal massages every fifteen minutes until the hiccups remitted. Doctor’s orders. The nurses massaged the patient’s rectum for the rest of the night, and for the next half-decade every nurse in the hospital made sure to page Cannon mercilessly every time he was on call. Cannon did not sleep much in residency, but he did teach me something about how medicine worked.
Up all night with surgical and medical services as a student, I was awed by their knowledge and exhausted by their work ethic, but realized that I did not belong on either team. I began to worry that I fit into no service at all.
When I started on the psychiatry service, I was dismissive, believing that it was not real medicine. I scheduled the rotation for December because I had already scheduled my wedding for January. My future wife, Elin, and I were classmates. We heard that psychiatry was a less demanding rotation than some others and figured it would give us time to finish our wedding preparations. I expected to be as uninterested in the work as I was in selecting flower arrangements. Instead, I found myself treating a drifter who walked around town with a backpack full of rocks because he believed that gravity had lost its hold on him. I met a sleepless young woman who filled pages of a notebook with equations purporting to show how the lyrics of pop songs reconciled classical and quantum mechanics. I met an addict whose drug of choice was Sanka per rectum. I found a team that offered what I liked best about medicine and surgery. Like internists, they deduced illness without disturbing the skin. Like surgeons, they addressed once-hidden issues. But psychiatrists were less interested in mapping illness or exploring pathology for their own sakes than in helping people learn to live with their individual realities. During those six weeks of psychiatry, I realized where I belonged. I married Elin and decided, to my surprise, that I was going to be a shrink.
When I finished the rest of my rotations, I enlisted in North Carolina’s psychiatry residency and traded my short white coat for the longer, but still anonymous, white coat of an intern. I was ascending Osler’s ladder. My first name receded from conversations, replaced by “Doctor,” and I started to carry the call pager.
On the second night of my internship, an exhausted colleague handed me the pager for the first time. She chuckled while shuffling out to the parking lot at the end of her thirty-hour shift. As she drove away, I realized that I was the last physician standing, the only on-call physician for a large state mental hospital named after its founder, the nineteenth-century social reformer Dorothea Dix. At its peak in the 1970s, the grounds of Dix Hospital unfolded over 2,354 acres that included three lakes, a working farm, a cemetery for deceased patients, and 282 buildings housing 2,756 patients. By the time I arrived, most of the acreage had been sold to developers, and most of the patients had been turned out onto the streets. In its diminished state, Dix resembled a failed nation-state, overgrown with stands of long-leaf pines, its remaining buildings falling back into the earth. Some buildings housed adolescent boys who yelled all night, others old men who slept all day. Some buildings sheltered women who plucked unseen bugs from the air, others girls who cut their legs open in red, ragged stripes. All told, the hospital accommodated up to 600 patients and was staffed by 1,300 administrators, cooks, custodians, nurses, physicians, and technicians.2
Most of these personnel worked during the day. At night, a few nurses staffed each unit. Their chief job was to keep the nights quiet, but nights were rarely quiet for the only physician in the building, the on-call intern. When I was on call, the nurses would page me for a sleep aid to silence a manic talker or an antipsychotic pill to pacify a paranoid mind. I welcomed the calls I could resolve with a one-time order for clonazepam or risperidone. I feared the calls that required me, no matter the hour or the weather, to drive across the dark hospital grounds to see a patient in person.
On those nights, the pockets of my white coat would be crammed full. In addition to a stethoscope, pocket manuals, and pens, I carried car keys, so I could move from building to building, and unit keys, so I could unlock the doors when I arrived. When I pushed through the heavy steel doors, their windows woven with steel wire, I could often hear the patient I had been paged to examine. If not, the nurses would direct me to a naked child smearing his feces inside a seclusion room or a crying woman banging her fists against an unbreakable window. My job was to speak with the staff about what had occurred, attempt to reason with the patient, write a note documenting the incident, and leave behind orders for medications. On those call nights I saw much more than it seemed a person should, witnessing these low moments in harshly lit rooms with aged linoleum floors that bore crude traces of all the other low moments that had come before. The work left its own traces on me.
I saw much and learned much at Dix. How to start intravenous fluids on a person who cannot keep still. How to distinguish a heart attack from a panic attack in a person who cannot speak coherently. But I also learned: Keep your distance. Offer only real choices. Make modest promises. Address only the most urgent matters now and put off to the morning everything else. Keep a checklist of everything you promised to do. Sleep when you can. Answer the pager when the admissions office calls.
The admissions office at Dix was located in the main building, next to the loading dock. Ambulances and police cruisers from across the state would back into the loading dock and release their cargo into the waiting room. One of the three admissions workers would check a patient in, while another would call my pager.
“You’ve got another patient.”
“Another?”
“Yes.”
“Okay, I’m over in the adolescent building checking out a bite. Little vampires. Then I promised the forensics unit I would assess a guy with the shakes. After that, I will be heading to . . .”
“You need to come now, this guy’s out of control.”
The admitting patients, like the forward guard of an attacking army, rose to the top of any checklist. There were no nurses in the admissions office, so I had to leave the bitten adolescents and the tremulous prisoners for later in the evening. Driving back across the grounds, the cemetery where unclaimed bodies were buried on my left, I arrived at the main hospital, where the admissions workers greeted each patient from behind a windowed wall. After they finished, I met each patient in an adjacent room, sitting if it seemed safe, standing near the door if it did not. I worked alone, becoming faster, if more facile, as the training progressed. What had taken me two hours as a student took me fifteen minutes by the end of residency. Working those night shifts, I learned to efficiently and effectively introduce myself, engage a patient, obtain a history, perform an examination, and develop a treatment plan. I developed instincts. I started to feel the rhythm of an examination, to know when I was sounding a false note and how to regain the rhythm when it faltered.
In all of this, Osler was proving to be right. My repeated, constant experiences in a rural outpost were training my vision, widening it until I could see much. I became a physician capable of admitting five, ten, fifteen, even twenty patients in a single shift, all while responding to emergencies on the rest of the campus.
But though I was becoming experienced, I was not becoming wise. Indeed, to get through the shifts, I learned to divide my attention. I cut patients off after I had heard enough of their story to complete my admission note. I learned to placate instead of listen.
I also learned to pinch myself on the wrist when I felt myself falling asleep. As fatigue enveloped me, I would be unable to stop my frustrations from leaking out. I would become short with the nurses. I began avoiding eye contact with patients and became more Cannon-like with every call. Ashamed by my behavior but exhausted by the demands, I retreated into myself, hiding out in the call room whenever I could. The room was furnished with castoff furniture: a lamp without a lightbulb, a bed with a rubber mattress manufactured during the Carter administration, a desk whose top was occupied by a television that received four channels when the weather was clear, a disposable telephone borrowed from a better hospital, five-year-old magazines whose glossiest pages were cemented together, takeout menus. The windows had been bricked in to allow for sleep whenever sleep was available. The room had its own toilet and sink, and a shower shared with the hospital’s spiders. Still, I would sit alone in the call room whenever I could, savoring moments of quiet. If time allowed, I would eat a greasy delivery dinner alone. An attending physician was available if I needed assistance, but he or she was always a phone call away, sleeping at home. When I did call the attending, he or she often sounded annoyed—I was an unpleasant reminder of their own experiences as a resident. I called the attending infrequently, but the frequency of calls to pager seemed to increase as the night progressed. By the early hours of the morning, as the calls escalated, my behavior had eroded. My questions grew shorter. My responses were reduced to grunts and nods.
But I held it together until early one morning I found the limits of my equanimity. A patient was in a diabetic crisis, and I had requested help that was not yet available. The patient’s nurse disliked the delay, so he “hammer paged” me every thirty seconds, demanding that I discontinue my orders for frequent blood draws. I explained my rationale, promised to search for another solution, and pleaded with him to stop paging me. All to no avail. He paged again and again, yelling at me each time I called back. Finally, I threw the pager across the call room, experiencing a frisson of delight as it shattered. Silence. Freedom from the professional minder. In the newfound quiet, I could see that dawn would soon arrive, and not longer after, sign-out.
Even the most dramatic nights ended with sign-out, at which I handed the pager over to the day team. Then I would return to the call room, shower, prop myself up with coffee pilfered from the nurse’s station, and go back upstairs to see my regularly assigned patients. When I finished that routine, I would escape to the parking lot, still wearing my white coat over hospital-issued scrubs. On the drive home, I listened to sports talk radio because the arguments kept me awake without involving me emotionally. I kept my hands on the wheel and tried not to hit anyone.
Or to hurt anybody at home. I shared a home with Elin and our two-year-old, Eamon. Elin and I were both on call every fourth night, so we staggered our nights so that one of us would always be home. We saw each other mostly in passing that year. One day, napping after a call night, I awoke to the sound of the front door. I went to check and found that Eamon had climbed out of his crib, opened the front door, and started toddling toward the street. I raced out of the house in my underwear, scooped him up, and locked the door behind us, wondering how the three of us would survive Osler’s residency curriculum.
. . .
Osler had been named the chief physician of the newly founded Johns Hopkins Hospital in 1888; by 1890, he and the rest of the Hopkins faculty were calling their trainees “residents” because the trainees resided at the hospital.3 By the 1900s, the American Medical Association was publishing lists of approved residencies. In these residencies, trainees would work every day and every other night. By midcentury, resident physicians were working thirty-six-hour shifts every other day, more than a hundred hours a week.
A typical example of this work ethic was endorsed by one of Osler’s protégés, Dr. Rufus Cole, in a commencement address to the graduating medical students at Cornell University in 1938. Cole began his speech by summarizing the sorry state of medicine before Flexner’s Report. Then he celebrated the transformation of medicine into a science in the years after Flexner. Through their schooling, Cole said, medical students acquired scientific understanding, but upon graduation they were not yet ready to practice medicine. They needed to acquire practical skills, and the only way to do this was “by practice itself and by unremitting hard labor” in a hospital.4
Since some internships were just open-ended visitations in which a recent medical school graduate spent as long at the hospital as he (most graduates at the time were men) felt necessary, Cole advised the graduates to seek internships in which trainees lived in the hospital as residents. “During your intern days, the hospital should be your home, your workshop and your playground. You should need nothing more. Learn to shun outside affairs that will complicate your life and disturb concentration on your work, rejoice if you are too poor to own an automobile to carry you from the straight road, avoid the movies, you will find sufficient tragedy as well as comedy close at hand, above all, avoid like a plague entangling affairs of the heart.”5 This was the kind of advice the protégés of Osler frequently gave. Work hard. See much. Avoid life outside the hospital. Stay away from movie theaters.
By the time I trained, the Oslerian model was still considered the ideal, but it was running up against new realities. Thanks to advances in medicine and changing criteria for hospitalization, the average patient in the modern hospital was more ill than during Osler’s era and required greater attention. The length of hospital stays was shorter. The expense of medical training and education had increased. In addition, medical school classes were now evenly split between men and women, making affairs of the heart harder to avoid.
For me, it was far too late to avoid them. Elin and I were committed to medicine, but we did not want the hospital to be anything more than a workshop. We did not need the hospital to be home or playground. We shared a home and lived near an actual playground, where our son delighted in the swings, his legs knifing through the humid air. Watching Eamon was a joy and a glimpse at an alternative model of care—instead of the quick fixes and crisis responses that we were learning in the hospital, our son was teaching us the accretive work of parenting.
Our playground visits were less frequent than he would have liked. To have enough money to pay for our son’s daycare, I often picked up extra, moonlighting, weekend shifts at Dix. Many evenings, we felt lucky if we could collect Eamon from his daycare before someone called social services, share a meal together, read a bit from a textbook or journal article after he went to sleep, and then find our way to our own bed. Cole had no reason to fear we would waste our training at the movies. But was this system truly the way to produce competent and caring physicians?
In March 1984, at a hospital affiliated with Cornell, the medical school where Cole had given his commencement speech urging “unremitting hard labor” a half-century earlier, an eighteen-year-old named Libby Zion died while her own physicians were half-awake. According to an account by the writer Natalie Robins, The Girl Who Died Twice, Zion was admitted to the Emergency Room with symptoms of agitation, fever, and flulike complaints. When physicians evaluated Zion, they could not piece these symptoms together into a compelling diagnosis and misdiagnosed a “viral syndrome with hysterical symptoms.”6 Zion’s physicians that evening, a first-year intern and a second-year resident, were working long shifts. They admitted her to the floor and ordered intravenous fluids and acetaminophen. Zion remained agitated, swearing and pulling out her intravenous lines; the resident ordered meperdine and, later, haloperidol. Then, while the resident retreated to an apartment across the street from the hospital for some furtive sleep, the intern worked her way around the hospital, seeing other patients while answering pages. Zion’s nurses paged the intern twice that night, concerned because Zion remained agitated and awake. The intern ordered that Zion be placed in a restraining vest. Zion finally fell asleep while the intern kept moving, working through her checklist. When a nurse checked on Zion later in the morning, she was running a high fever and could not be roused. And then her heart stopped. Libby Zion died less than a day after being admitted to the hospital.
An autopsy was ordered, but the results shed little light on Zion’s death. It wasn’t until years later that a consensus was reached that the biological cause of Zion’s death was serotonin syndrome, a rare adverse medication reaction. Before she arrived at the hospital, Zion had probably been using cocaine and marijuana, along with the prescribed drugs chlorpheniramine, diazepam, erythromycin, flurazepam, oxycodone, and phenelzine. Phenelzine is a nonselective and irreversible monoamine oxidase inhibitor that can effectively reduce depressive symptoms but is often difficult to tolerate. When a person ingests phenelzine, it prevents several neurotransmitters—dopamine, epinephrine, melatonin, norepinephrine, and serotonin—from being degraded, so more of these neurotransmitters are active in the body. It also, however, prevents the degradation of tyramine, a component of fermented foods, smoked meats, many cheeses, and most alcohols. Ingesting these foods while taking a drug like phenelzine can result in a dangerous elevation of blood pressure.
Taking phenelzine and cocaine in combination with meperdine, a synthetic opiate better known by the trade name Demerol, and haloperidol, a dopamine-blocking agent that is commonly used to reduce agitation, can also lead to dangerous, even lethal, levels of serotonin. As serotonin increases in the body, the person can become agitated and tremulous, experience diarrhea and a fever, begin to sweat or shiver. Each of these symptoms can be caused by thousands of diseases, so piecing them together into a single diagnosis, serotonin syndrome, is challenging. Zion’s physicians were not up to the challenge. I suspect I would not have been either.
Errors occur often in the hospital. I remember being on call once when a resident ordered ten times the usual dose of a furosemide, a diuretic, for a patient. The patient received the dose before the resident realized her mistake. The resident immediately disclosed the error to the patient, the patient’s family, our attending physician, and the hospital. The resident was disconsolate, but the patient’s family said they understood. The family remained understanding even when the patient died the next day. The patient was elderly, and the family felt that she had made her peace with dying.
Zion’s family was not so forgiving; their daughter was only eighteen years old. Zion’s father, an attorney and journalist, subsequently dedicated his life to correcting the kind of error that led to her death. But what exactly was the error? Was it that Zion had received fragmented medical care both outside the hospital, where she received medications from her college’s physicians along with her home dentist, gynecologist, pediatrician, and psychiatrist, and inside the hospital, where at least five separate physicians were involved in her care in the space of eight hours? Was it that the patient did not disclose her illicit substance use and her prescription drug misuse to the admitting physicians? Was it that the resident physicians missed a difficult diagnosis? Was it that the hospital lacked pharmacy safeguards to prevent the administration of medications that could cause serotonin syndrome? Was it that the resident physicians were insufficiently supervised by attending physicians? All these factors seem relevant to the tragic death of Libby Zion.
But Zion’s family concluded that the error was the “unremitting hard labor”—the long duty hours—of the residents on call. They launched a crusade that led first New York State, in 1999, and then all accredited American residencies, in 2003, to limit a resident’s workweek to eighty hours and shifts to no more than thirty hours. In 2007, the United States Congress asked the Institute of Medicine to explore the association between medical errors and resident work hours. In its 2008 report, the institute recommended that, whereas a resident’s workweek could extend up to eighty hours, an intern shift should last no more than sixteen; that residents working thirty hours should have at least five hours nap time; and that moonlighting should be discouraged.7 In 2011, the Accreditation Council for Graduate Medical Education (ACGME), which accredits most of the eighty-five hundred or so American medical training programs, implemented an even stricter version of these rules. A trainee can now work up to eighty hours a week, but interns can only work up to sixteen-hour shifts and residents only up to twenty-four-hour shifts.8 The surprising outcome, though, is that while today’s trainees may theoretically have more time to catch a movie, their shifts have become even more demanding.
In this century, Osler’s training model has been transmuted from in-house residencies into high-pressure shift work. Far from living in the hospital, today’s residents come and go constantly. They are issued pagers, but most prefer to use their own smartphones, devices that even more precisely track their comings and goings. They need to keep track, because they arrive and depart at prescribed times, sometimes literally being sent home in the midst of caring for a patient because they have reached the end of their allowed duty hours. At the beginning of their training, a more senior physician supervises them, and residents are given more responsibility only after they are deemed competent to work alone. They have to read about the effects of fatigue and sleep deprivation. They are provided with more regular supervision from attending physicians.
I envy the schedule of contemporary residents. These changes were phased in after I completed my internship, and I can see their benefits. I remember feeling abandoned in the hospital, trying to figure out how to care for a patient with little assistance. I remember the fatigue of being on call every fourth night for months on end. I remember the errors that occurred while I was exhausted, most modest, but some devastating. I remember feeling distant from my friends, my family, my wife, and our son. I know that in today’s system, I would never have been left as the only physician on call for a hospital as vast as Dix on the second night of my residency, or allowed to moonlight on my days off.
But I also wonder how today’s trainees will learn all that I learned at Dix. Today’s interns and residents have limited opportunities to develop their ability to care for a patient on their own. Instead of admitting a patient who has been seen by no one but an admissions worker assessing vital signs and reviewing demographic data, the residents with whom I now work admit patients only after they have been examined and stabilized by a member of our faculty in the psychiatric Emergency Department. Instead of following a patient throughout his or her first thirty hours of hospitalization, these residents follow the patient for a few hours. Instead of admitting twenty patients and caring for twelve during a day, they admit fewer than ten and care for six.
In this new system, in which residents are constantly passing off patient care to another resident, a different set of errors has arisen. In our hospital, a single patient is handed off four times between residents in a twenty-four-hour period. With each handoff, errors can occur; it’s like a game of telephone. And though residents work fewer hours, each of those hours is more full than it was during Osler’s era, when patients lingered in the hospital. The hours of today’s residents are also filled with new professional responsibilities for transitions in care, responsibilities that pull them away from the bedside.
As a result of these changes, residents are starting to understand their training as a job with clear boundaries: this number of patients for this shift. If a patient with an interesting problem comes in at the end of a shift or if resident is in the middle of working with a patient, he or she still has to leave. Attending physicians often say that they fear this system stunts the growth of the best residents while discouraging weak residents from testing themselves appropriately for the rigors of practice. Attending physicians also worry that residents will learn to practice independently only when they become attending physicians themselves—there are still no duty hour requirements on attending physicians.
In his 1938 commencement speech, Cole advised graduating students, “The hospital should not treat interns as employees, make them punch a time clock (of course figuratively) and provide to the minutest detail the kind and amount of work they shall perform.”9 Less than a century later, we do treat residents as employees, and the time clock is literal. Today’s residents log each hour they work with patients as a “duty hour” on online scheduling programs and are penalized if they exceed the allowed hours by mere minutes. In this way, we penalize today’s residents for seeing much. Residency training programs are similarly penalized when residents “violate duty hours.” Residency training programs that do not obey duty hours and other requirements will receive citations and, if they continue to violate duty hours, lose their accreditation, effectively shuttering a training program for being unprofessional.
So if medical association charters provide the aspirational version of professionalism and pagers enforce professionalism by regulating time, then today’s residents are experiencing professionalism as mandated by regulatory agencies. Although the available evidence about the duty hours system suggests that it is improving the didactic education and quality of life of residents, it also suggests that reforming medicine by regulating the hours of physicians is making medicine more costly, fragmented, and bureaucratic.10
Reforming medicine through professionalism focuses on the actions of an individual physician; in most such attempts at reform, organizations and committees draft consensus statements describing how an individual physician should behave. As manifestations of such reform measures, pagers have become a way to enforce the requirements of professionalism, to ensure that a physician is available and engaged in his or her responsibilities. The control pagers can exert, however, is limited. In a literal sense, the pagers worked in Libby Zion’s case. The nurses paged the intern. The intern replied and remained engaged in her professional responsibilities to her patient. Zion still died in the hospital. And the reform of residency duty hours—the fruit of Zion’s death—has endangered Osler’s famous model of residency as an opportunity to see much.
The debate about how to preserve Osler’s model in the context of duty hours is ongoing, but reformers are increasingly looking beyond pagers and duty hours for other ways to regulate physician behavior.
I am, too. The image I think back to is Osler’s vision of the physician as a ship’s captain, ferrying his patients across a figurative sea of illness or injury. What if a physician bore responsibility for his or her patients throughout the journey, instead of forever handing off the patient to the next physician? I rarely saw a physician take that kind of responsibility in my residency. Instead, what I saw was a new hope that we could fix medicine not by making physicians more professional or humane but by compelling them to follow the rules of evidence.