Of sleep deprivation
September 2, 2003
Being a physician sometimes makes one look back and ponder about the long and difficult journey one has taken to reach the pedestal: the pride and prestige of becoming a doctor. The thought oft passes our minds that we, unlike lesser mortals, spent more time, more money, and more sleepless nights to get to where we are now (successful or not, rich or not, we are doctors nevertheless). Unlike them who spent a mere 4 or 5 years of college, we had 4 years of pre-med, 4 years of med school, 1 year as "PGI" then 3-5 years of residency and another 2-3 years of fellowship. And all those years were pretty much spent awake (I hope), through the college of sleep deprivation.
As medical students and trainees, why must we sleep so little to learn so much? Why do we have to work so hard to be proficient enough?
|
"The busier it gets, the more dangerous it becomes. The tired, stressed out and sleepy doctor is less efficient and proficient. Would you like to be a patient at the other end if you had a choice?"
|
The answer may be summarized into: "so much information, so little time". When we sign up for training, we get immersed into a surrogate family, where seniority takes precedence and takes on the role of disciplinary parenthood. Just like rank and class in the military or the organizational ladder in offices: the hospital is a system, complicated yet simple: just follow the orders till it is your turn to give them. Then as each batch moves up, it subjects the neophytes to the same torture it suffered. It seems a necessary evil for a reason, so that the medical factory produces astute physicians. Indeed, as it is said, "the road to hell is paved with good intentions," and that road is full of sleepless nights through the training in sleep deprivation.
Of course, the harder the course, the longer the duration, the more painful the process, the greater the pride. Every upper-class officer knows this in the military academy, just as every consultant does who trains students, interns and residents. There is indeed value in hard work. A paragraph missed in a medical book or one procedure not assisted in training can mean the difference between life and death in the future when you become the consultant yourself. Then there would be no regret about those long sleep deprived nights of studying, being on duty, or operating under the consultant’s name when the consultant is fast asleep.
Oops, that last clause did not sound right. Just like too many sleepless nights does not sound right. There is abuse, ghost surgeries and inadequate supervision all in the guise of education: forcing the student or trainee to overwork, overtime, and get sleep deprived at the expense of patients’ lives. Not all the mentors are honest, smart or industrious themselves, and serve poor examples if not shameful ones.
Medical students pay too much just to get abused then become interns, residents or fellows and get abused even more while being the worst underpaid laborers in the planet.
* * *
In the Philippines, there is no governing body dictating the number of hours a resident is supposed to work. There are minimum requirements for specific procedures, operations, and duration of training, but no definite rule on work hours. In the United States, the Accreditation Council for Graduate Medical Education governs and accredits residency training programs. Due to past history of medical disasters from overworked, under slept staff, rules have been implemented and more recently further modified, to limit work hours for the safety of the both the patient and the medical staff.
The new regulations limit duty hours to 80 hours per week, with a minimum of at least 10 hours between shifts. Each resident must have at least one 24-hour day every week free of any medical duties. On call (in the Philippines, "On Duty") should be no more frequent that every third night and no one should be continuously working for more than 24 hours at a time but can extend by another 6 hours at most if needed (such as completing a long surgery, attending rounds next morning, or stabilizing a critically ill patient).
In simpler terms, this means not being "On Duty" more than 3 times in a week, being able to go home before noon the next day when you are "Post Duty", and you are not supposed to be called back for ghost surgery from 7 PM to 5 AM the next day. PLUS, of course, a full day off per week without being paged once (or one full weekend off every 14 days!!!!).
Currently, even in the US, an average resident is estimated to work about 95 hours per week, 30% of which is spent doing "scut work" (drawing blood, changing dressings, transporting patients, performing EKG’s, checking vital signs, etc) .In my memory and discourse with colleagues in the Philippines, we do waaaaaay more that 95 hours weekly and do a lot mooooore scut work. And this does not necessarily translate into learning, but exhaustion and sleep deprivation.
But how can this be implemented, even imaginable in the Philippines that could barely hire enough residents, much less pay them half a teacher’s salary? It is utopian at worst and implausible at best. Most residency programs are tiny and accept only a few applicants per year. If there were 2 residents per year, there will be too few people to go on duty every third night. If a senior and a junior surgical resident go on duty together in one night, they will be "toxic" all night especially if there are multiple trauma victims in the WVSUH or WVMC emergency room on a Friday night. Two OB-Gyne residents in Iloilo Mission Hospital will be hard pressed if there were a dozen deliveries that night not to mention Ceasarians and retained placentas. Two internists in St. Paul’s or Iloilo Doctor’s would be inadequate in a 300 bed hospital especially if there are 12 people on ventilators and inotropic support plus 5 codes and 200 ER visits. A couple of Pediatric residents will be hard pressed to cajole a score of neonates and preterms and do spinal taps and IV insertions at the same time.
The busier it gets, the more dangerous it becomes. The tired, stressed out and sleepy doctor is less efficient and proficient. Would you like to be a patient at the other end if you had a choice? Do you know how sleep deprived that chief resident is who now holds a No. 15 scalpel above your navel? Worse, he might be drugged or drunk as you and I have known a few. And where is the attending consultant? Is it then also a surprise, to see all these flunkers in the residency or diplomate exams?
Hey, but things don’t get much better when you become an attending consultant either. Now you become the captain of the ship, the supposed know it all, the end of the line, where the bucket stops. Now, even though you need not stay in the hospital for 36 hours at a time, you are actually responsible for patients you relegate to the trainees 24 hours a day, 7 days a week, even if you are frolicking in Boracay or swooning in Sandpipers. Well, at least you earn more and don’t get yelled at. But you can get sued.
* * *
The perils of the patients do not end with disheveled doctors. There are tired nurses too! If my memory does not fail me, there are usually only 2 or 3 nurses in each nursing station: at least in A-up and C-up years ago as it is probably to this day. Back in the UH, these 3 nurses serve an entire floor with 30 or more patients. The work is hard, especially bowing to a doctor doing rounds then carrying several charts while stuttering behind him then patiently waiting for orders to be barked. Then there is the risk of occasionally being berated and scolded by the doc after being treated like a maid by a patient who feels like the hospital is a hotel.
Well, at least some areas are "owned" by the nurses who "lived" in the area for years, (such as the UH OR and ICU for example), where they have the "right" to scream at greenhorn interns rotating in the area. But most of the time, the nurses in the Philippines are also overworked and more underpaid. That is why they are all in America, London or Jeddah where the pastures are greener and they do not have to bow down to doctors or carry the charts for them.
But it is not all just green pastures in the US of A. In a survey by the American Federation of Teachers-Healthcare division, three out of five hospital nurses say they care for too many patients. For cost saving purposes, hospital administrators save money by assigning more patients to each nurse, usually up to eight patients per shift instead of five recommended for medical-surgical wards (wow, they complain of 8 patients per nurse here, let them see the ratio in WVMC or WVSUH!). The American Medical Association even recommended in its journal in 2002 that nurses should not care for more than 4 patients at a time (except in intensive care where the ratio should be 1:1 or 1:2), otherwise, the likelihood of mortality increases significantly. In fact, in nursing homes here, the situation is just like in the third world: a couple of nurses care for up to 50 screaming, soiling, demented, "complete" patients. At least, they have CNAs, LPNs, or "techs" to help them wipe those white or black behinds during their shifts. More often than not however, these natives are too lazy to haul their asses to do their jobs though, and the tiny 5 foot Filipina nurse has to do the dirty task themselves which is preferable to risking a fight with a female Mike Tyson look alike. Once again, tired or sleep deprived nurses can also mean adverse effects on healthcare.
We have not even mentioned the statistics on how many medical personnel get killed or maimed while driving asleep after being on duty for 36 hours or after a 16 hour nursing shift.
Sometimes, we all feel like hanging this sign outside the hospital gate: "Don’t get sick, I’m tired."
* * *
* * *
Views expressed on this column and any other by-lined articles on this site are the authors' own and do not necessarily reflect the views of the organization or its members.
