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Residents, duty hours, and respect

The following is an email I received.

I, a surgical resident, would like to ask for help navigating conversations about resident duty hours. You had a very strongly worded post on the subject. My intent is not to contradict your perspective, but perhaps get and give some insight on this question. First, I wish to show you the conversation with a surgeon “fossil” as I experience it:

Fossil: “In my day we worked __ many hours and operated all night and never slept or ate and were glad of it. It made me the surgeon I am today. You will never have this privilege.”

Me: “Wow, I agree. You had it much harder.” Meanwhile, I am thinking:

▪Working 120 hours a week made you good surgeon. Just because it worked, doesn’t make it right. No human being should have to suffer for their job like that. And no patient deserves a surgeon that tired.
▪I wish I could operate with you more. I wish those notes and discharge summaries and case manager hadn’t kept me away from most of this case. And the one yesterday. And the one tomorrow.
▪Operating is a privilege and an honor. I would gladly work those hours if it meant I could operate.
▪Please stop implying that I am lazy and entitled for being dissatisfied with some aspects of my training.
▪Please help me learn to be a good surgeon despite all the issues listed above – but particularly with more to know, and less time in the operating room

The conversation above touches on issues of respect and understanding, as well as very real frustration with residency training as it is today. For me, it touches on three major points:

First, respecting the “fossils.” Since the development of residency, surgeons have been forged through long work hours, incredible dedication, and no small amount of suffering. This formed ingrained knowledge that cannot be taught, that comes from repetition and practice. A surgeon coming out of this training will know the right thing to do at 9 am or at 3 am. There is no debate that this sort of training makes good surgeons.

Second, problems with historic residency training. The lack of duty hour restrictions took (and still takes) an incredible toll on a surgeon’s life, both physically, mentally, and emotionally. Long work hours have been at the cost of sleep, personal relationships, and personal well-being. The errors made while sleep deprived are also undeniable. While muscle memory helps, you are still impaired after 24, 48, or 72 hr call, and the toll of this on our patients cannot be known. To say “you knew this when you signed up for it” is dismissive. No, I didn’t know, nor could I have. And once I signed up for it, for me to switch careers would be financially disastrous.

Third, problems with current residency training. Many believe we need to know more and do more in less time than the generations before us.

▪Going from 120 hrs to 80 hrs occurred with no increase in staffing. Those 40 hrs did not disappear, they pulled residents out of the operating room to do paperwork.
▪There are more operations to know, and we must now know them open, laparoscopically, and even robotically.
▪Patients are older and sicker.
▪Medical knowledge is expanding exponentially. There are more diagnosis and treatments to remember every day
▪There is more paperwork, charting, and phone calls per patient, and an increasing team to coordinate around this patient (PT, OT, nurses, case managers, wound care, social work).
▪Increased “floor” demands without staffing leads to more “scut” work for the residents. Scut has its value, but only to a certain extent.
▪Residents who have done fewer operations get less autonomy. Which leads to less autonomy. Which leads to less operating.

I often go days or weeks without operating because there is floor work to do. Minor cases go without resident coverage. I rarely do “teaching” cases with senior residents, and I have never had time to “just drop in” to another case to help or learn when I’m on the clock. Rarely can two residents operate with an attending, or a senior resident take a junior through a case, there is just too much to do elsewhere. This is in a program considered non-malignant, with higher than average cases per resident, and with a program director who does support us and enforces duty hours.

We each think our own training was harder for myriad reasons, but to hear that I will never be as tough or good as those before me shows a lack of respect for the work I have put in and the priorities I have made in my life, including that of surgery. I as a resident can promise to respect the experience and knowledge of those who went before me, and appreciate the incredible work that they have done to get where they are. I also will probably never work those hours, and am stuck in a broken system with diminishing returns.

So, what do I say to this? Do I just agree with the fossil—yes, they did have it harder? Or is there a way to respectfully ask how do I get as good as you are in this completely different training setting?

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