Round and round

Life as I know it is one of dependance on other people's time. Most jobs don't rely wholeheartedly on schedules of only a few- but in medicine, it's all about the attending. For those who don't know this, the atteding is the top of the pyramid. Yes, there's the CEO, the chair, the chief- but most of us don't see them on the wards with any regulariy. We see the attending. And when we see the attending is one of the most interesting components of hopital life.

Even since I graduated from medical school in 2005, lots has changed. The 80 hour/week mandated work rules were put into place which were supposed to create a safer working environment for doctors and patients. Stories of car crashes following 40 hour shifts and accidents (most notoriously the case of Libby Zion- beautifully summarized here http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html) led to these changes. Hence us young trainees actually leaving the hospital at decent hours and having a semblance of a life outside of medicine kicked off officially one year prior to my starting training as a medicine resident. This was seen by most young docs, at the time, as a terrific move. The post-call intern was relieved of duty, on most days, at a reasonable hour. Calls were never more than 24 hours long except in the ICU where they lasted up to 36 hours. Night float residents were assigned to cover all admissions after 8:30pm until 7am, allowing interns to go home and sleep a bit. (We never got out at 8:30- more like 1am).

But here I sit, less than one year graduated from my residency- and I am beginning to wonder if those reduced hours helped me or hurt. And this leads back to the attending. The truth is- with all of those hours NOT being worked by the interns and residents, someone had to step in and work harder. That someone was the attending. I have informally been polling my attending physicians on a multitude of services for 3 years and have universally found the same response to my inquiry about whether or not the work hours have affected their lives: BIG TIME. Doctors already average >60 hour work weeks once they are attendings. Those in the teaching hospitals where I have worked for my post-med school career average >80 hours. The increased hours are due to a bunch of factors. Doctors in academic settings are under extreme pressure to bring in money for the hospital. This can be in the form of grants or in clinic time. Some specialties, like gastroenterology and cardiology are procedure oriented and thus have lots of billable services. Others, like nephrology, endocrinology, neurology- are solely office visit based and are "supported" by their money making counterparts. Whichever division an attending works in, he or she has a packed schedule- and one which requires lots of hours for a combination of grant writing, lab research, clinical research, teaching duties, clinic time, and now more and more committee obligations. The attendings bring home the bacon- and the attendings work for it.

So how does this affect me? Why do I care (other than the fact that one day not too long from now I'll be "attending" myself?) Well, last week I got home at 8:45pm 3 times and at 7pm 2 other times. This was because my attending couldn't round with the team until 5:30pm due to her responsibilities in the endoscopy suite, and when she did, rounds were interrupted by phone calls from her patients, and her secretary. Rounds were interrupted by her co-grant writer calling just before a deadline. And when she taught- we looked at the clock. We didn't want to- but we are spoiled now on 80 hour weeks. We are spoiled by 15 minutes with our kids before they go to sleep, and spoiled by the ability to eat a 9pm dinner. We want out at the end of a 14 hour day. And while 10 years ago out wasn't an option- we new-generation doctors know that out is as important as in the hospital.

And all of this isn't only due to the 80 hour work rule- soon to be amended to 56 hours of maximum work a week per resident- but someone has to do that work, and no one is feeling sorry for attendings. After all, they bring in the bacon.